Acute and chronic oropharyngeal stick injury in dogs:
What protocol should be followed?
Karolien de Vor, BSc.
k.devor@students.uu.nl
Veterinary Medicine, Master Companion Animal Medicine, Research Project
Faculty of Veterinary Medicine, Utrecht University, the Netherlands
May 4, 2011
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
Abstract
When dogs play with, chew on or persistently carry sticks, injuries to the mouth, pharynx
and possibly the oesophagus could occur. Acute oropharyngeal stick injuries (when the
incident has been less than seven days ago) and chronic oropharyngeal stick injuries (when it
has been more than seven days) can be dangerous and even life threatening. The University
Clinic for Companion Animals at the Faculty of Veterinary Medicine in Utrecht therefore has
a protocol for the treatment of these cases. With the combination of a literature study, a
patient review of 32 client owned dogs treated for (possible) acute or chronic stick injury at
the UCCA between 2004 and 2011 and an evaluation of two surveys held among the patient
owners and attending veterinarians, this protocol was reviewed for suitability and usability.
It turned out that the protocol was largely in agreement with the current literature and was
redeemed clear and understandable by the veterinarians who treated the patients. Most
veterinarians used the protocol during treatment of their patient. Twenty-five dogs made a
full recovery after treatment, five dogs died or were euthanized and the in two dogs the
problems still remained after initial treatment. Looking at these results and positive
comments from the veterinarians, it seems the protocol is suitable for treatment of
oropharyngeal stick injury and usable by veterinarians. However, some improvements could
be made, including a differentiation between acute and chronic oropharyngeal stick injury
and the approach of the chronic case will have be described. Furthermore, the postoperative treatment should be added. The results of the literature study on how to handle
patients with oropharyngeal stick injuries was combined with the approach described in the
current protocol and the comments made by the veterinarians on what they thought of the
protocol and what they would like to see into a new protocol. This protocol consists of a
decision tree for a quick overview of the approach of acute and chronic cases of
oropharyngeal stick injury and contains a step by step explanation of each step that should
be taken during treatment of these patients.
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
Contents
1
2
3
Introduction ...................................................................................................................... 3
Materials & Methods ........................................................................................................ 4
Results............................................................................................................................... 5
3.1 Who are the patients? .................................................................................................. 5
3.2 How to handle acute and chronic cases of oropharyngeal stick injury according to
current literature ........................................................................................................ 12
3.3 The UCCA Protocol and the treatment at the UCCA .................................................. 16
3.4 Surveys ....................................................................................................................... 18
4
Discussion ....................................................................................................................... 21
5
Conclusion....................................................................................................................... 24
6
Acknowledgements ........................................................................................................ 25
7
References ...................................................................................................................... 26
Appendix I: Klinische Richtlijn STOKTRAUMA ......................................................................... 27
Appendix II: The management of pharyngeal stick penetration injuries in dogs ................... 29
Appendix III: Protocol voor de behandeling van stoktrauma bij de hond .............................. 31
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
1
Introduction
Oropharyngeal stick injury - injury to the mouth, pharynx and possibly the oesophagus,
caused by a wooden stick - occurs mainly in dogs that play with sticks (i.e. retrieving sticks),
persistently carry sticks in their mouth or chew on them.1-6 According to previous research,1,3
oropharyngeal stick injury is usually seen in dogs with an average age of around 4.5 years
and weight of around 25 kg, belonging to medium to large breeds, possibly because these
breeds show more stick chasing activity, are heavier and move faster. Another possible
reason is the way dogs from bigger breeds hold their head while retrieving sticks: smaller
dogs are able to pick up sticks from the ground in a head up position, in comparison to larger
dogs that pick up sticks with a head down position that exposes their pharynx to injury.1, 3, 6-8
Especially Border Collies, Labrador retrievers, Springer spaniels, German shepherd dogs and
crossbreds are frequently affected. There is no predisposition regarding the sex of the
dogs.1,3
Dogs with oropharyngeal stick injuries are typically divided into two groups: acute cases
(presented within seven days after the incident) and chronic cases (presented after seven
days).1-3, 6-8 The presenting signs differ remarkably between the two groups. Acute patients
show more severe and systemic signs whereas chronic patients, which are more frequently
seen, show less severe signs and hardly ever present with systemic disease.1
Dogs with acute oropharyngeal stick injury often show signs of dysphagia, hypersalivation
(possibly with blood mixed with the saliva) and oral pain.1, 3, 4, 9 Without treatment this can
lead to depressed behaviour, loss of appetite, swelling of the cervical region, dyspnoea and
shock.2, 4 Dogs with chronic oropharyngeal stick injury, on the other hand, are mostly bright
and alert.1 They typically manifest abscess formation, fistulas and discharging sinus tracts of
the head and neck regions,1, 3, 4, 8, 9 as a result of migrating wooden fragments that remained
present in the patient.5
Acute and chronic oropharyngeal stick injuries can thus be a dangerous and even life
threatening situation, especially when there is a large abscess formation and/or rupture of
the oesophagus.1, 3, 4
Because unnoticed injury or unsuccessful management of acute cases can lead to chronic
cases,4 and a potential life threatening situation that can occur, it is important that
veterinarians know how to examine and treat animals with such injuries. A clear and suitable
protocol should be used as a guideline in these cases. The University Clinic for Companion
Animals at the Faculty of Veterinary Medicine in Utrecht has been using a protocol (shown in
Appendix I and Appendix II in a Dutch and an English version)10 since March 2006. The aim of
this research is to investigate if this protocol is suitable for the treatment of acute or chronic
oropharyngeal stick injury and whether it is useful for the veterinarians treating these cases.
A suitable protocol is defined as a protocol that has a success rate (all problems solved) of 90
per cent in acute cases and 80 per cent in chronic cases when its instructions are followed.
These percentages are based on the success rates in two previous studies. White et. al.
(1988)1 found a success rate of 73.3 per cent in acute cases and 88 per cent in chronic cases.
Griffiths et. al. (2000)3 found a success rate of 100 percent in acute cases and 62 per cent in
chronic cases. This means the average success rate in acute cases is 87 per cent and 75 per
cent in chronic cases. These percentages are rounded off to 90 and 80 per cent, because
current knowledge and techniques should enable higher success rates.
An useful protocol is defined as a protocol with clear instructions in the form of a decision
tree. The results will be used to improve the protocol, if necessary.
3
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
2
Materials & Methods
This research project is a combination of a literature study, a patient review and an
evaluation of two surveys. For the patient review 32 patient records from the patient care
information system Vetware were used. These are the records of dogs that were presented
with acute or chronic oropharyngeal stick injury at the University Clinic for Small Animals
(UCCA) between 2004 and 2011. One of the surveys was held among the patient owners to
find out how the patients were doing after they received treatment at the clinic. Some of the
questions that were asked were: “Was the problem solved?”, “Were there complications?”,
“Did the problems return?”. Owners whose dog died during or shortly after treatment were
therefore excluded from the survey. The other survey was held among the veterinarians that
treated these patients when they were presented at the clinic, to find out if they
encountered any problems using the protocol and if the protocol is easy to use.
The results of this literature study, patient review and evaluation of the two surveys will be
used to answer the following questions:
 Who are the patients that were treated at the University Clinic for Small Animals?
 What is the advice on how to handle acute and chronic cases of oropharyngeal stick
injury according to current literature?
 Is the current protocol used at the University Clinic for Small Animals based on the
knowledge from literature?
 Is the protocol used at the University Clinic for Small Animals effective/sufficient?
4
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
3
3.1
Results
Who are the patients?
The medical records of 32 animals with acute or chronic oropharyngeal stick injury,
presented between 2004 and 2011 at the UCCA at the Faculty of Veterinary Medicine in
Utrecht, were reviewed. The signalement (breed, age, sex, weight) and other clinical data
(history of stick injury, time passed since the stick injury or first symptoms, presenting signs
and results of treatment at the UCCA) are presented in Table 1 (acute cases) and Table 2
(chronic cases). Their breed distribution, a summary of the clinical examination and the
outcome of treatment at the UCCA are summarized in Table 3 and Table 4.
Of the 32 dogs, thirteen cases were acute (40.6 per cent) and nineteen cases were chronic
(59.4 per cent). The 32 dogs were equally distributed between the sexes (16M:16F), and had
a mean age of 4 years and 5 months (with a range of 11 months to 10 years, 3 months) and
mean weight of 30.5 kg (with a range of 13.5 kg to 46.0 kg). The distribution of the dogs by
breed showed the group of shepherd dogs (Belgian, White, German, Dutch and Australian
shepherd dogs) to be more frequently represented (28.1 percent). Other commonly
presented breeds are the crossbred dog, the Labrador retriever (and crossbreds) and the
Border collie (and crossbreds).
In 24 of the 32 dogs (75 per cent) the owner was aware of the occurrence of stick injury. This
rate is highest in the acute cases, with known stick injury in eleven out of thirteen cases
(84.6 per cent), whereas in the chronic cases the occurrence of stick injury was known in
thirteen out of nineteen cases (68.4 per cent). The remaining six patients were suspected of
chronic oropharyngeal stick injury because they were known to play with or chew on sticks
and thus were treated as such.
In nineteen of the 24 dogs with known stick injury (79.2 per cent) and in three of the eight
dogs with unknown stick injury (37.5 per cent), one or multiple foreign bodies were found
during surgery. So in total, foreign bodies were found in 22 cases (68.8 per cent), with eight
out of thirteen acute cases (61.5 per cent) and fourteen out of nineteen chronic cases (73.7
per cent).
In patients with acute stick injury, depressed behaviour, swelling of the neck region and pain
were the most common symptoms. Other symptoms in this patient group were pyrexia,
anorexia, tachypnoea, bleeding. Subcutaneous emphysema occurred in three of the
patients, as did hypersalivation. Other symptoms are described in Table 1.
The chronic patients, on the other hand, all presented with an abscess or swelling in the
neck region. Eleven of the nineteen dogs had discharging sinuses or a recurrent, fluctuating
wound which (periodically) ruptured. Other common symptoms seen in this group were
panting or tachypnoea, and fever, although the latter less frequently than the former. Some
dogs were pyrexic, some had enlarged lymph nodes and some had a stridor. More
symptoms are listed in Table 2.
In the end, a total of twenty-five cases resolved after receiving treatment at the UCCA.
Unfortunately, one dog died and four were euthanized because of their oropharyngeal stick
injury (15.6 per cent). Three of these dogs had acute stick injury (23.1 per cent of the acute
cases) and two chronic stick injury (10.5 per cent of the chronic cases). Two dogs (both acute
cases) were euthanized during surgery because of complete dehiscence of the oesophagus
in one case and because of the extent of the oesophageal tear in the other. The third dog
with acute oropharyngeal stick injury was euthanized after surgery when he suffered from
bleedings that could not be controlled. The dog with chronic oropharyngeal stick injury was
euthanized when treatment did not resolve the problems and a cause could not be found.
The last dog, another chronic case, did not do well after his surgeries and died shortly after
the last operation. Lastly, two chronic cases remained unresolved after initial treatment at
the UCCA. Both dogs had a recurring fistula.
The success rates are thus 77 per cent in acute cases and 79 per cent in chronic cases.
5
Table 1. Epidemiological and clinical data for 13 dogs with acute oropharyngeal stick injury treated at the UCCA
Case #
Breed
Age
Sex Weight
Known
Duration
Presenting signs
(kg)
stick
injury
1002302
Labrador
8y
MN 44.6
+
2d
Fever, lethargy, anorexia, adipsia,
retriever cross
swollen neck, tachypnoea;
oesophageal tear, perforation
under tongue.
1007411
Belgian
1y
M
29
+
3d
Bleeding, anorexia; fracture of
shepherd dog
the hyoid bone.
411923
White
2y, 8m
FN
33
+
1d
Lethargy, fever, anorexia, adipsia;
shepherd dog
oesophageal tear.
FB
found
Comments
Result
+
Explore. Drainage provided. Repair
mucosal defect. Piece of wood and
several wood fragments removed.
Resolved
-
Explore. Drainage provided. During
surgery arterial bleeding.
Explore. Found expansive
necropurulent phlegmonous
infection. Drainage provided. After
2 weeks dehiscence wound,
surgery to close the wound; after
1.5 weeks again dehiscence and
surgery. 3 days later again
dehiscence, dog was euthanized.
Explore. Removal of stick. Drainage
provided. After surgery swelling,
pain, regurgitation (possible
damage of the n. vagus) and
infection in the neck region.
Explore. Removal of FB, presence
of seropurulent material. Drainage
provided.
During endoscopy development of
subcutaneous emphysema,
pneumomediastinum/-thorax.
Explore. Drainage provided. 2nd
surgery: removal of stick from
thorax. Drainage provided. After
surgery infection in mediastinum.
Inspection throat, removal of stick.
Explore, removal of wood
fragments. Drainage provided.
Resolved
-
600888
English bulldog
1y, 11m
F
27.8
+
1.5 hr
Lethargy, stick visible at the level
of the scapula, pain, tachypnoea;
perforation under tongue.
+
601603
Border collie
6y, 1m
F
14.2
+
1d
+
602666
Border collie
4y, 3m
F
21.1
+
<1d
Anorexia, swelling under larynx,
emphysema in the thorax;
perforation under tongue.
Bleeding, anorexia, adipsia;
perforation under tongue.
702114
Crossbred
9y, 7m
FN
35
+
3 hr
Lethargy, some subcutaneous
emphysema around trachea and
larynx, swelling around
oropharynx; perforation on the
left side of the frenulum.
+
6
+
Died
Resolved
Resolved
Resolved
Resolved
800438
Crossbred
10y, 3m
FN
23.9
+
2.5 hr
802679
American
Staffordshire
terrier
1y, 10m
F
21.5
+
1d
802919
German
shepherd
4y, 6m
M
43
+
1d
805305
Golden
retriever
2y, 5m
M
32.1
+
4d
903324
Crossbred
4y, 11m
M
13.5
-
<1d
1003791
Bernese
mountain dog
cross
7y, 1m
M
44.1
-
2d
Pain, vomiting, tachycardia,
bleeding, stick stuck in the throat
from epiglottis to left scapula;
perforation soft palate,
oesophageal tear.
Some bleeding, anorexia, adipsia,
lethargy, swollen throat;
perforation next to tongue base,
fracture of the hyoid bone.
Bleeding, lethargy; tear in right
dorsolateral cheek. Piece of stick
removed by own veterinarian.
+
Inspection throat, removal of stick,
repeat inspection throat. Due to
severe tear of the oesophagus and
costs the dog was euthanized.
Died
-
Explore. Tear debrided, ventral
side left open to make drainage
possible.
Resolved
+
Died
Bleeding, anorexia, adipsia, stick
palpable in larynx (removed by
own veterinarian), panting,
restless, swelling of larynx area;
perforation under tongue.
Gagging, vomiting of white
mucus, dysphonia, sensitive
throat, swelling neck region,
subcutaneous emphysema,
laryngeal stridor,
pneumomediastinum.
+
Explore. Drainage provided. 3 days
after surgery severe arterial
bleeding, area explored again:
bleeding from the base of the
skull, wooden fragment found in
hematoma. Bleeding stopped but
started again during recovery,
could not be controlled, dog could
not be extubated, so was
euthanized.
Explore. Removal of several FB.
Drainage provided.
Resolved
Lethargy, anorexia, adipsia,
panting, drooling, pharyngeal
stridor, larynx oedema, swollen
tongue, partial obstruction
oropharynx, swollen neck region.
-
Unknown trauma, possible stick
injury. Throat inspection,
tracheoscopy. Next day (after
swelling coming down) repeat,
explore: perforation anterior
airway. Wound healing per
secundam.
Unknown trauma, possible stick
injury. Explore (difficult because of
oedema). Drainage provided.
M = male, MN = male neutered, F = female, FN = female neutered
FB = foreign body
7
-
Resolved
Resolved
Table 2. Epidemiological and clinical data for 19 dogs with chronic oropharyngeal stick injury treated at the UCCA
Case #
Breed
Age
Sex Weight
Known
Duration
Presenting signs
(kg)
stick
injury
509439
Shepherd dog
7y, 3m
M
42.2
+
9d
Mild swelling of throat,
pharyngeal expiratory stridor;
thickness left to the larynx.
1003235
Bordeaux dog
4y
FN
43.1
+
1.5 y
Recurring abscess in neck region
since 1.5 years, first abscess
appeared 1 month after stick
injury. Slightly increasing in size;
purulent infection and scar tissue.
Decreasing stamina.
1005809
Belgian
shepherd dog
Golden
retriever cross
3y, 7m
M
34.3
+
10 d
11m
MN
19.5
-
4w
1008437
Crossbred
3y, 8 m
FN
36.5
+
1y, 2m
1008917
White
shepherd dog
1y, 1m
M
34
+
5m
507981
Labrador
retriever
Hovawart
2y, 6m
FN
31
+
5w
7y, 6m
M
38.5
+
1.5 y
Dutch
shepherd dog
5y, 9m
FN
20.9
+
1.5 y
1005940
509167
407671
FB
found
Comments
Result
+
Explore. Small piece of wood
removed. Drainage provided.
Resolved
-
Explore. Drainage provided. No
FB or other cause found. After
surgery recurrence of the
abscess occurred twice (2nd
time not responding to
antibiotics), owners decided to
euthanize the dog.
Explore. Wood fragment
removed. Drainage provided.
Unknown cause; dog is known
to play with sticks, and played
with bamboo sticks 5 weeks
ago. Explore, drainage
provided.
Explore. 2 wood fragments
removed. Drainage provided.
Died
+
Explore. Wood fragment
removed. Drainage provided.
Resolved
+
Explore. Wood fragment
removed. Drainage provided.
Explore. Wood fragment
removed. Drainage provided.
Resolved
Explore. Small fragment of
plant material removed.
Drainage provided. Almost 3
months later recurrence of
fistula.
Unresolved
Thickness in neck region, pain,
drooling.
Thickness under right mandibula,
exponential growth last week,
coughing (mostly during exercise).
+
Growing thickness in neck region,
several months after stick injury
over a year ago; fever.
Recurring thickness in neck,
painfully, since stick trauma;
lasting fistula.
Firm thickness near mandibula
and above sternum, since 2 days.
Stick trauma 1.5 years ago, since 6
months recurring thickness in
neck region, filled with purulent
material.
Recurring thickness in neck
region, persisting fistula; wound
will not close.
+
8
-
+
+
Resolved
Resolved
Resolved
Resolved
606677
Belgian
shepherd dog
cross
1y
M
25
-
4w
Coughing, lethargy, since 9 days
growing thickness in neck region
near larynx, trouble with
swallowing, fever, inspiratory
stridor.
Anorexia, trouble with
swallowing, difficulty opening
mouth, nasal stridor, tachypnoea,
tachycardia, swelling from
mandible up to under the left
carpus, hemopurulent exudate,
extensive oedema.
-
610248
Rottweiler
5y
MN
46
-
12 d
609531
German
wirehaired
pointer
6y, 8 m
FN
30.8
-
7m
Fistula on left side of the neck,
distal to the cricoid, at the level of
the thyroid gland, filled with
purulent material; fever.
+
703647
Crossbred
3y
MN
28
+
7w
+
29
-
5w
Recurring abscess formation,
growing thickness under
mandibula, with fistula and
infected.
Thickness under throat, septic
purulent infection; coughing,
gagging, anorexia, weight loss.
706477
English bulldog
1y, 8m
MN
902548
Border collie
cross
5y, 10m
M
25
-
3m
Problems started 3 months ago,
since 2 months thickness near
throat, variation in size, slowly
increasing; purulent infection.
+
905469
Labrador
retriever cross
4y, 10m
FN
21.5
+
8m
Recurring thickness, variating in
location and size; infection with
fistula.
+
9
-
+
Unknown cause, dog likes to
chew on sticks. Ultrasound
shows presence of FB, but was
not found during surgery.
Drainage provided.
Unknown cause, possible stick
injury but also had spareribs
and threw up bone splinters.
Explore. Drainage provided. No
indication of FB. Skin died.
Possible secondary aspiration
pneumonia. Dog died;
pathology also showed maligne
lymphoma.
Unknown cause, used to play
with sticks a lot. Ultrasound
showed FB. Explore, wood
fragment removed. Drainage
provided.
Explore, wood fragment
removed. Drainage provided.
Resolved
Unknown cause, dog is known
to play with sticks. Explore. 2
grass spikes removed. Drainage
provided.
Unknown cause, dog likes to
play with sticks. Ultrasound
shows signs of FB. Explore: no
signs of FB. Drainage provided.
Recurrency week later. Explore,
thickness with 3 small wood
fragments removed. Drainage
provided.
Explore. Wood fragment
removed. Drainage provided.
Resolved
Died
Resolved
Resolved
Resolved
Resolved
907112
906873
908023
Labrador
retriever
Staffordshire
bull terrier
Australian
shepherd
3y, 3m
FN
31.6
+
6w
Abscess in throat, with fistula.
+
5y, 2m
FN
31.1
+
9m
+
4y, 10m
FN
25.5
+
2y
Recurring swelling throat,
variation in size, panting.
Fistula at the level of the larynx,
pus outflow since 3 months.
M = male, MN = male neutered, F = female, FN = female neutered
FB = foreign body
10
-
Explore. FB removed. Drainage
provided.
Explore. Wood fragment
removed. Drainage provided.
Stick trauma at 1 or 2 years of
age. Ultrasound showed FB.
Explore. No FB found. Rupture
of blood vessel to thyroid gland
with major bleeding. Successful
stopping of the bleeding. No
drainage. Recurring fistula 1
month later, treated with
antibiotics.
Resolved
Resolved
Unresolved
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
Table 3. Distribution by breed
Number of Cases Percentage
Shepherd dog + cross
9
28.1
Crossbred
5
15.6
Labrador retriever + cross
4
12.5
Border collie + cross
3
9.4
Golden retriever + cross
2
6.2
English bulldog
2
6.2
American Staffordshire terrier
1
3.1
Staffordshire bull terrier
1
3.1
Bernese mountain dog + cross
1
3.1
Bordeaux dog
1
3.1
Hovawart
1
3.1
Rottweiler
1
3.1
German wirehaired pointer
1
3.1
Total
32
100.0
Table 4. Outcome summary in 32 cases of oropharyngeal stick injuries treated at the UCCA
Acutely presented
Chronically presented
FB removed
No FB removed FB removed
No FB removed
Resolved
6
4
12
3
Unresolved
2
Died
1
Killed
2
1
1
FB = foreign body
11
Total
25
2
1
4
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
3.2
How to handle acute and chronic cases of oropharyngeal stick injury
according to current literature
When handling dogs with (possible) oropharyngeal stick injury, it is important to first
determine whether the stick injury is acute (less than seven days since the trauma) or
chronic (more than seven days since the trauma), since acute cases should be handled in a
different manner than chronic cases.
Acute cases
Treatment of dogs with acute oropharyngeal stick injury has two goals: resolving the
problems the dog has at the time of presentation and preventing the development of
chronic complications.1 To achieve these goals, urgent management of the injury is
necessary.1 Since acute oropharyngeal stick injury can be potentially life threatening with
the development of dysphagia, dyspnoea and/or shock, first-aid attention should always be
the first step of treatment.1 As the general emergency protocol describes, the veterinarian
should make sure there is nothing present in the oropharynx causing an obstruction of the
airway (i.e. blood, tissue debris, swollen tongue) and that haemorrhages are controlled.1
After the patient is stabilized, the extent of the wound should be determined. In superficial
penetrating injuries the wood is often immediately removed from the pharynx of the dog by
the dog itself or by the owner dislodging the stick,1 although this not always the case. In
deeper penetrating wounds wooden fragments can remain in the soft tissues of the neck
region. These remaining fragments can migrate and cause chronic suppuration if left in the
tissue.1, 3
The veterinarian should also try to determine whether or not the dog suffers from
oesophageal injuries,1 since penetration of the oesophagus has a much more guarded
prognosis than other forms of pharyngeal trauma.1, 2 This is because healing of the
oesophagus is difficult due to constant movement from swallowing and respiration and
because complications such as dehiscence, stricture and fistulation are common. The lack of
serosal covering of the oesophagus, lack of omentum, segmental blood supply, constant
motion and distention of the oesophagus with passage of food boluses have been suggested
as possible reasons for these complications.11 In addition, the enzymes present in the saliva
for the digestion of food also interfere with the wound healing. Because of the more
guarded prognosis and possible complications, dogs with oesophageal trauma require more
intensive care.1, 2 With endoscopy the extent of the oesophageal lesions can be assessed.1
Cervical and thoracic radiographs should be taken not to try to locate the foreign
body/bodies, since wood is not visible on radiographs,3, 7, 8 but to evaluate the possible
development of cervical subcutaneous emphysema, pneumomediastinum or
pneumothorax.1-3 These findings all suggest deep penetration and possible presence of
wooden foreign bodies.7 Subcutaneous emphysema is frequently seen in dogs with acute
penetrating oropharyngeal and/or oesophageal injuries,2, 12 as are loss of soft tissue
structures, lacerations and cellulitis.12
In the mean time dogs must be withheld from oral intake of food and water to limit the
chances of mediastinal contamination.1
After radiography, the dog should be anaesthetised in order to thoroughly inspect the
mouth, pharynx, larynx and proximal oesophagus.1, 9 To be able to determine the full extent
of the injuries, the soft palate should be retracted rostrally.1 There are several types of
wounds that can exist: rostral pharyngeal wounds near the tonsils, dorsal pharyngeal
wounds, lateral pharyngeal wounds (the most common type of wound) and wounds under
the tongue.1, 5
Following the inspection of mouth and pharynx, all pharyngeal wounds and cervical soft
tissues should be explored via a ventral midline approach from larynx to manubrium, with
12
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
the dog in dorsal recumbency.1, 2, 4, 11 In this manner the important neurovascular structures
of the neck can be identified and there is access to both sides of the neck to explore the
tissues.4 Rostral pharyngeal wounds, however, might have to be approached orally as well
due to anatomical limitations in the ventral cervical approach.2 However, the exploration of
the neck region should also be performed, since the exit of the penetration tract will be
lower than the entry site and foreign bodies could therefore very well be present in the neck
region.
The parapharyngeal, retropharyngeal and cervical tissues will have to be explored for
possible presence of any foreign bodies, which all have to be removed, and to investigate
the extent and severity of the injuries.1, 2 Special attention should be directed at the dorsal
wall of the oesophagus at the level of the cricopharyngeus muscle when injury of the
oesophagus is suspected.3 Placing a probe per os into the oesophagus might be helpful to
find any perforations in the oesophagus.13
After exploration of the tissues, tears in the pharynx and/or oesophagus will have to be
repaired and traumatized tissues lavaged to reduce microbial contamination.2 Lacerations
should be repaired with a one or two layer simple interrupted suture pattern (depending on
the location of the laceration of the oesophagus), using absorbable sutures.1-3, 11, 13
Next, drainage will have to be provided by inserting one or more Penrose drains that exit the
skin through a separate skin incision next to the original incision. The drains can be removed
when the wound is not productive anymore.1, 8, 9
If indicated, antibiotics can be administered post-operatively to clear any infection and to
prevent the development of chronic suppuration.1 Literature on when this is indicated,
however, is not conclusive. Some say to only treat dogs with topical and systemic broad
spectrum antibiotics when a wooden fragment has been removed,1 while others treat all
dogs with antibiotics.2 Use of steroidal drugs should be avoided, since these drugs can
suppress the rejection of foreign material that might have been left behind.1 In addition to
antibiotics, analgetics should be administered,1, 2, 4 for example opiates or non-steroidal antiinflammatory drugs.4 In cases with moderate to severe oesophageal damage, it might be
advisable to place a gastrostomy tube to temporarily avoid feeding the dog orally.14
Chronic cases
Chronic cases are more difficult to diagnose and treat than acute cases. Problems can
therefore last for weeks, months or even years.1, 9 The diagnosis of chronic oropharyngeal
stick injury itself is often presumptive, since some cases present without any known history
of stick injury and because traces of the original wound are difficult, if not impossible, to
find. Assessment of the injury is therefore limited.1
Because these cases often present with abscess formation, fistulas and discharging sinus
tracts of the head and neck regions, the first step of treatment should be to differentiate
between the different causes of these sinuses, such as a foreign body, chronic aural disease
and infections with Actinomyces species are possible causes.1, 9 Diagnostic imaging can
provide the necessary information to do so and, in addition, provides useful information
about the extent of the abscess and presence of foreign bodies.4 It is helpful for the surgeon
to know if he or she should expect to find a foreign body during surgery.12
There are several types of diagnostic imaging available, namely radiography, sinography or
fistulography, ultrasonography, magnetic resonance imaging and computed tomography.4, 8,
15
The choice between these diagnostic tools depends on availability, risk to the patient,
benefit and cost.4
Radiography in chronic cases is of little use, since wooden foreign bodies in soft tissue are
not visible and abnormalities that might occur in the acute state are often resolved in the
chronic patient (i.e. subcutaneous emphysema and pneumomediastinum, the reasons to
take radiographs when a dog presents with acute oropharyngeal stick injury).3, 8
13
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
Sinography, on the other hand, depends on the presence of an external draining sinus1, 4, 8
and thus is not useful when this sinus does not exist in the patient. In addition, sinography
rarely localizes any foreign bodies.9
Ultrasonography is useful in detecting foreign bodies and provides information about the
size, shape and location of foreign bodies and the extent of the problem.8, 15 The surgical
approach can therefore be more direct, with less tissue damage and decreased surgical
time.8 In addition, ultrasounds require only light sedation or no sedation at all, unlike
computed tomography (CT) and magnetic resonance imaging (MRI) for which the dog needs
to be sedated or anesthetized. Ultrasound is also readily available and relatively inexpensive
compared to CT and MRI.4 Downsides to ultrasounds are the requirement for operator
experience, familiarity with the region being examined and possible false positive diagnosis
because bone fragments and mineralization can appear as being foreign bodies.15 Another
limitation of ultrasonography is the inability to image deep to air and bone,8 which can be
problematic in the oropharyngeal region and around the larynx, where bone and air are
predominant.
Like ultrasound, MRI and CT are helpful in effective surgical planning1 by providing a lot of
information about the extent and location of traumatized structures.2 MRI is more effective
in determining the extent of soft tissue inflammation than ultrasound and CT, which poorly
differentiates the inflammatory response from the surrounding tissue.2, 8 MRI and especially
CT also provide accurate information about the presence, size, shape and location of foreign
bodies.2, 8, 12 MRI, however, is not of great use in predicting the number of wooden foreign
bodies or localizing other types of plant material.8, 12 Compared to MRI, CT is less expensive.4
This is due to another benefit of CT compared to MRI, namely the shorter anaesthesia time
that is required in CT (fifteen minutes in CT compared to ninety minutes in MRI).
The pros and cons of these different diagnostic imaging approaches are listed in Table 5.
After diagnostic imaging, surgery is the next step in the treatment of the chronic case.1, 9 If
the dog is being treated with antibiotics and/or steroids, this treatment should be
discontinued well before surgery,1, 9 since these drugs tend to suppress the suppurative
reaction1 and cause formation of fibrous tissue around the foreign body.9 This makes it more
difficult to locate the foreign body and to distinguish nerves around it during surgery.9
Surgery of the chronic case is basically the same as the acute case, starting with inspection of
the pharynx and larynx.1, 3, 9 Even though it is usually impossible to find the original wound,1
this inspection should be performed, since finding the site of injury gives information about
the possible penetration tract of the foreign body.3 In addition, in some cases the sinus
drains into the pharynx,1 which will be found during this inspection. However, the original
site of injury is less important than the eventual destination of the foreign body/bodies and
the site of the abscess.3 Inspection of the pharynx and larynx should thus be followed by
inspection and exploration of the neck region by means of a ventral mid-line incision from
larynx to manubrium.1, 3, 4 During surgery, sinus tracts should be explored via longitudinal
incisions to try to find and remove the foreign bodies that might be present and cause the
chronic inflammation.1, 3 It is suggested to resect all affected abnormal tissue in order to
remove all small pieces of foreign material with the debrided chronic inflammatory tissue.1, 3
However, in practice, this is almost impossible to do because of the risk of damaging any
important structures present in the neck region.
Next, all abscesses should be opened, inspected for presence of foreign bodies,9 the lining
debrided with gauze swabs and then lavaged with sterile saline.4 Before closure of the
incision, drainage should be provided with one or more Penrose drains in the same way as in
the acute case.1, 4, 8, 9
Post-operative care should consist of IV fluid therapy until oral feeding is resumed4 and
administration of analgesics (opiates, non-steroidal anti-inflammatory drugs) and
antibiotics.1, 4
14
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
Table 5. Pros and cons of diagnostic imaging in patients with (possible) chronic oropharyngeal stick injury
Diagnostic imaging
Pros
Cons
Radiography
Relatively inexpensive; readily
Wooden FBs are not visible;
available
abnormalities that might occur in
the acute state are often resolved
in the chronic patient; not of
great use in chronic cases
Sinography/fistulography
Aid to investigate retained
Depends on the presence of an
radiolucent FBs; useful if sinus is
external draining sinus; rarely
present
localizes any FBs
Ultrasonography
Able to detect (wooden) FBs;
Requires operator experience;
informs about size, shape and
requires familiarity with the
location; informs about the
region examined; possible false
extent of the problem; helpful in
positive diagnosis because bone
effective surgical planning;
fragments and mineralization can
requires only light sedation or
appear as FBs; unable to image
none at all; readily available;
deep to air and bone
relatively inexpensive
Magnetic resonance imaging
Helpful in effective surgical
Not of great use in predicting the
planning; informs about extent
number of wooden FBs; unable to
and location of traumatized
localize other types of plant
structures; most effective in
material; requires long sedation
determing the extent of soft
or anaesthesia; relatively
tissue inflammation; informs
expensive
about presence, size, shape and
location of FBs
Computed tomography
Helpful in effective surgical
Poorly differentiates the
planning; informs about extent
inflammatory response from
and location of traumatized
surrounding tissue; requires
structures; gives most accurate
sedation or anaesthesia;
information about presence, size, relatively expensive
shape and location of FBs; less
expensive than MRI; anaesthesia
time is a lot shorter than in MRI
FBs = foreign bodies
15
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
3.3
The UCCA Protocol and the treatment at the UCCA
With the aid of the medical records in Vetware, the way the patients were treated at the
UCCA was reviewed and compared to the UCCA protocol. Because treatment of the acute
patient is different from treatment of the chronic patient, they will be discussed separately.
Acute cases
As described in the UCCA protocol, veterinarians should start with the general emergency
protocol. In reality, this happened in eleven of the thirteen cases. In the other two cases the
veterinarian started with a regular physical examination and auscultation of the lungs (and a
full examination of heart and lungs in one of the two dogs).
The next step in the protocol is taking radiographic images of the neck and thoracic cavity. In
most cases, some form of radiographs was taken, but not in all. As shown in Table 6, cervical
and thoracic radiographs were taken in four of the thirteen cases, radiographs of only the
neck region or only the thorax in respectively one and two cases. In one case it was indicated
to get a radiograph of the mandible as well as the neck region. Two owners brought the
radiographs taken by their own veterinarian to be evaluated at the UCCA. Finally, in three
cases no radiographs were taken at all. In one of these cases, however, radiographs of the
thorax were taken at a later point in treatment, when endoscopy of the oesophagus had
lead to a pneumomediastinum/pneumothorax with severe subcutaneous emphysema.
After radiography, the protocol indicates the inspection of the pharynx under general
anaesthesia as the following step in treatment. In practice, this happened in all but one case.
In this one case, the veterinarian first performed explorative surgery, after which she
repaired the wound in the mouth.
All dogs had to undergo one or more surgeries. Explorative surgery was performed in ten
cases, one of which only in the second surgery (in the first surgery tracheoscopy was
performed, but swelling made examination difficult). In the other three dogs exploration of
the neck region did not occur or in a different manner. In two of these dogs the stick was
visible from outside, therefore surgery was aimed at removal of these sticks. In the third dog
clinical examination, radiography and exploration of the penetration tract did not indicate
presence of remaining wooden fragments or other abnormalities in the neck region.
Explorative surgery should take place with the dog in dorsal recumbency and with a ventral
midline incision, as it did in all but the two dogs previously described. Because of the
different type of surgery in these dogs, their position during surgery was also different in
order to successfully and safely remove the stick. In stead of a ventral midline incision the
skin over the stick was incised.
Flushing the surgical area with sterile saline is described as optional in the protocol. In most
cases, eight out of thirteen, it did not happen. Drainage should be provided, preferably with
one or more Penrose drains. These drains were indeed placed in eleven cases, one wound
was left partially open to drain and in one case no drainage was provided at all.
Not mentioned in the protocol, but part of the treatment, is the post-operative therapy. All
dogs received antibiotics and analgesics after surgery, except two dogs that were euthanized
during surgery.
Table 6. Diagnostic imaging in the acute cases treated at the UCCA
Number of Cases
Cervical and thoracic radiographs
4
Thoracic radiographs
2
Radiographs neck region
1
Mandible and cervical radiographs
1
Evaluation of radiographs taken by own veterinarian 2
None
3
Total
13
16
Percentage
30.8
15.4
7.7
7.7
15.4
23.1
100.0
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
Chronic cases
Where veterinarians should start treatment of the acute case with the general emergency
protocol, in the chronic case a regular physical examination and examination of the abscess
and possible draining sinuses is more conventional. This examination was performed in
sixteen of the nineteen chronic cases, whereas the general emergency protocol was
followed in the other three cases.
According to the UCCA protocol, diagnostic imaging is especially important in the treatment
of chronic cases, since management is directed at residual foreign body retrieval. As Figure 1
shows, ultrasonography is by far the most used type of diagnostic imaging. It was used in all
but one case, where computed tomography was used to determine the presence and
location of a possible foreign body. Ultrasonography was the type of diagnostic imaging used
in fifteen patients, and was combined with CT or thoracic radiographs in one respectively
two other cases. In three dogs, ultrasonography was repeated just before or during surgery
to try to localize the foreign bodies. In three other cases, additional diagnostic imaging in the
form of ultrasonography, CT and a combination of MRI, ultrasonography and CT was needed
because the problems did not solve or recurred after surgery.
After diagnostic imaging, the dogs underwent surgery. The UCCA protocol indicates that the
principles of pre-surgical inspection of the pharynx and oesophagus, the surgical techniques
and drainage are the same as in the acute cases. Inspection of the pharynx, however, did not
occur in eight of the nineteen cases. As for the exploration of the neck region, this took place
in all cases. While all dogs were placed in dorsal recumbency as described in the protocol, a
ventral midline incision was made in only ten cases. In the other nine cases, the surgeon
chose a different type of incision, most often an incision over the abscess or a ventral
paramedian incision.
Flushing the operation site in these chronic cases was done in only three cases. Drainage was
provided in almost all cases with one or more Penrose drains. In only one case it was
decided to close the wound without providing drainage, as the surgeon did not find any
foreign bodies and the area was not visibly contaminated.
Post-operative therapy consisted of antibiotics and analgesics in fifteen cases and just
analgesics in the remaining four.
Figure 1. Diagnostic imaging in the chronic cases treated at the UCCA
17
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
3.4
Surveys
Two surveys were held, one among the patient owners and one among the veterinarians
that treated the patients. The results are described below.
Patient owners
After excluding the five owners whose dog died during or after surgery, 27 remained and
were called to ask to participate in the survey. One owner could not be reached, the other
26 did participate. They were asked how their dog did after being released from the UCCA, if
the problems the dog had were resolved after treatment and if not, what the problems were
that stayed or occurred later and if they were treated for these problems. Finally the owners
were asked what they thought of the treatment their dog received at the UCCA.
Twenty-four owners (92.3 per cent) said that their dog was doing fine after being released
from the UCCA, the remaining two owners could not answer this question because it was
too long ago and therefore could not remember.
The next question was if the problems the dog had when they were presented at the UCCA
were resolved after treatment. This was the case in all dogs that had suffered from acute
oropharyngeal stick injury. Among the dogs with chronic oropharyngeal stick injury,
however, two dogs (11.8 per cent) still had problems. One dog had an infection with a
festering wound, the other had a recurring fistula. In the first dog, the owner was able to
remove a small wooden foreign body from the wound, about a week after treatment at the
UCCA. After this little piece of wood was removed, the problems solved on their own. The
second dog was first put on antibiotics, but when this did not solve the problem the owners
went back to the UCCA. Here, an additional ultrasound indicated the presence of a foreign
body, which was successfully removed during surgery and resolved the problems.
In the end the problems in all dogs were solved, including in the two dogs where the
problems initially remained unresolved after treatment at the UCCA. Three dogs, however,
did end up with a thickening around the wound area and one dog had a slightly decreased
lung capacity due to the treatment she received (this dog had a stick removed from her
thorax). None of the dogs were treated for these problems, mainly because it did not affect
them or, in one case, the dog was old and had several other problems for which the owners
decided euthanasia was the best option.
Lastly, all owners were content about the treatment their dog received at the UCCA.
Veterinarians
Between 2004 and 2011, 26 veterinarians were involved in the treatment of the 32 dogs that
were presented at the UCCA with acute or chronic oropharyngeal stick injury. In most cases,
the veterinarian who did the physical examination of the dogs prior to surgery was not the
veterinarian who did the surgery. Therefore, both were asked to participate in the survey.
A total of fifteen veterinarians eventually participated in the survey: six who only did the
physical examination, five who only did the surgery and four who did both, although not in
every case they have treated. Two of the remaining eleven veterinarians no longer worked
at the UCCA and had left no contact information, therefore a survey could not be sent to
them. Four other veterinarians did respond, but could not answer the questions in the
survey because they either did not remember the case well enough, or only assisted in the
case and were not responsible for the decision making progress. One veterinarian
mentioned he was involved in the treatment of a chronic case and therefore did not use the
UCCA protocol. However, he was supervised by a specialist during this treatment. Finally, the
remaining six veterinarians did not respond and thus did not participate in the survey.
The veterinarians were asked if they were aware of the availability of the protocol. This was
the case in all but one. This veterinarian was not sure if the protocol existed at the time she
treated a dog with oropharyngeal stick injury.
18
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
The veterinarians were also asked whether their approach of a case with oropharyngeal stick
injury is based upon experience, the protocol, the advice of a fellow veterinarian, literature,
something else or a combination of the previous. The answer is shown in Figure 2 and Figure
3. Most veterinarians base their approach on their own experience and the protocol
available at the UCCA. Getting advice from another veterinarian, preferably a specialist in
this field, is also common among the veterinarians. As Figure 3 shows, most veterinarians
rely on multiple sources during treatment of dogs with acute or chronic oropharyngeal stick
injury.
When presented with a case of a dog with oropharyngeal stick injury, nine of the fifteen
veterinarians used the protocol during treatment, five did not and one cannot remember if
she did. Among the veterinarians who only did the physical examination, two used the
protocol, the other four did not. Among the five surgeons, four used the protocol. Finally,
three out of four veterinarians who have been doing both the physical examination and the
surgery, three used the protocol.
The most important reasons to use the protocol were that it is helpful to have a protocol,
the veterinarians always try to base their approach on a protocol and because the protocol is
based on the literature and contains clear instructions from a specialist. Reasons they gave
on why they did not use the protocol were that they already knew the contents and because
they already consulted or would rather consult the specialist. Two other reasons were that
the case presented in the middle of the night and therefore they did not get around to using
the protocol, the other was because the veterinarian believed the protocol was made for
acute cases of oropharyngeal stick injury and not chronic cases.
The veterinarians who did use the protocol were asked if they found the protocol clear and if
they came across any problems. One veterinarian could not answer these questions because
this happened too long ago. The other eight veterinarians found the protocol clear and did
not have any problems with it, except for one. She was not sure if she could still use the
protocol because a few days had already passed since the trauma happened and she did not
know if she should still treat the dog as if it was an acute case.
Because the aim of this research is to try to improve the protocol, if and where possible, the
veterinarians were asked if they had any remarks on, or points of improvement for the
protocol. The veterinarian who was not sure if she could still use the protocol would like
longer existing stick injury to be accounted for in the protocol. Another veterinarian would
like to know if neck exploration is still indicated if inspection of the pharynx, physical
examination and radiographs show that there are no indications for other perforations other
then one beneath the tongue. In addition, one veterinarian would like the reconstruction
and repair of wounds in the pharynx to be explained in more detail. Lastly, one veterinarian
indicated a decision tree would be useful.
Finally, the veterinarians were asked if they think if diagnostic imaging in the form of
radiographs and/or ultrasounds is useful in these cases and why. Most do think it is for
several reasons: it is important to check for emphysema, pneumomediastinum, diagnostic
imaging can confirm the suspicion of oropharyngeal stick injury, it might provide more
information about the cause and the extent and localization of the problem, it might detect
the foreign body and it can be helpful to decide whether or not to surgically explore the neck
region. Four veterinarians, however, did have some side notes. One veterinarian does think
ultrasound might be useful, but it depends on the type of foreign body. Another does think
radiograph and ultrasound might be useful in acute cases, but CT or MRI can also be used in
the chronic case. A third veterinarian thinks only radiographs are useful. Finally, the last
veterinarian thinks diagnostic imaging is only useful in chronic cases, since surgery is far
more meaningful in acute cases.
19
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
Figure 2. Case approach
2
experience
0
10
6
protocol
advise other
veterinarian
literature
other, namely …
10
Figure 3. Case approach in more detail
20
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
4
Discussion
Who are the patients that were treated at the University Clinic for Small Animals?
Patients with oropharyngeal stick trauma are mostly dogs from medium to large breeds,
especially Border Collies, Labrador retrievers, Springer spaniels, German shepherd dogs and
crossbreds. They are on average four and a half years old and weigh around 25 kg. Males
and females are equally distributed. Most patients have the chronic form with abscesses
and/or fistulas.1, 3 The patients treated at the UCCA fit into this picture quite well. Their
mean age was four years and five months. They were a bit heavier, with an average weight
of 30.5 kg. The dogs belonged to the bigger breeds, with Shepherd dogs, Labrador retrievers,
Border Collies and crossbreds as the most represented breeds. There were as many male
dogs as there were female dogs. Most patients indeed had the chronic form.
The symptoms the patients at the UCCA had are also conform the literature. The acute
patients showed signs of depressed behaviour, swelling of the cervical region, pain, pyrexia,
anorexia, tachypnoea, bleedings, subcutaneous emphysema and hypersalivation. The
chronic patients presented with abscesses, swelling of the neck region and discharging
sinuses.
What is the advice on how to handle acute and chronic cases of oropharyngeal stick injury
according to literature?
The first step in treating a dog with an oropharyngeal stick injury is to determine whether
the injury is acute (less than seven days since the trauma) or chronic (more than seven days
since the trauma), since their approach differs.
The acute case should first receive emergency treatment according to the general
emergency protocol. After the patient is stabilised, the extent of the wound should be
determined, including examining if the oesophagus is involved in the injuries. Next, cervical
and thoracic radiographs should be taken and examined for signs of penetrating trauma and
signs for presence of wooden foreign bodies, such as subcutaneous emphysema,
pneumothorax and pneumomediastinum. The wooden foreign body itself is unlikely to be
seen on the radiograph. After the dog is anaesthetised, the mouth, pharynx and oesophagus
should be inspected and an explorative surgery of the neck region should be performed via a
ventral midline incision to remove any present foreign bodies and to repair the wounds.
After drainage is provided with one or more Penrose drains, the wound can be closed. Postoperatively, the dog should receive analgesics and antibiotics if indicated.
In the chronic case, the first step of treatment should be to determine the cause of the
abscess and/or sinus. Diagnostic imaging in the form of ultrasonography, CT or MRI can
provide the necessary information and provides information about the extent of the abscess
and presence of foreign bodies. Radiography in the chronic case is of little use and
sinography depends on the presence of a sinus and is less reliable in locating the foreign
body than ultrasonography, CT and MRI are. After diagnostic imaging it is time for surgery.
This is largely the same as in the acute case, starting with inspection of the mouth and
pharynx, followed by exploration of the neck region. All abscesses should be opened and
explored, as should the sinus tracts. The lining should be debrided and then lavaged with
sterile saline. As in the acute case, drainage should be provided with one or more Penrose
drains, after which the wound can be closed. Post-operative therapy should consist of IV
fluid therapy, analgesics and antibiotics.
Is the current protocol used at the University Clinic for Small Animals based on the knowledge
from literature?
When comparing the UCCA protocol with the approach described in literature, it is evident
the UCCA protocol is in agreement with this approach. While both the protocol and the
21
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
literature describe what to do while treating a dog with oropharyngeal stick injury,
experience of the specialist has made the UCCA protocol more practically oriented, with step
by step instructions for the veterinarian to follow and to perform.
As shown in the appendices, the UCCA protocol exists in a Dutch version, readily available
for veterinarians at the clinic, and a translated English version. These versions are largely the
same, but do have some differences. Where the English version describes both the approach
to the acute and the chronic case, the Dutch version focuses predominantly on the acute
case. However, even though the English version has mentioned the treatment of the chronic
patient, this approach was described less specifically than the approach of the acute patient
and focused more on the types of diagnostic imaging. Both the approach and diagnostic
imaging are described more fully in literature.
In addition, both versions of the protocol are missing a clear description of the acute and
chronic patient. This description can be useful for veterinarians who have trouble deciding if
they should still treat a patient as if it were an acute case, or if the approach of the chronic
case is the better option.
Also missing in the UCCA protocol is the post-operative therapy. This is part of the treatment
of patients with oropharyngeal stick injuries and therefore should be mentioned in the
protocol. However, post-operative therapy does depend on how the patient is doing after
surgery and if analgesics and especially antibiotics are indicated or not. It is therefore
difficult to generalise this in the protocol.
Is the protocol used at the University Clinic for Small Animals effective/sufficient?
According to the survey held among the veterinarians, most of them know about the UCCA
protocol and often use it. This might not always be exactly step by step and the protocol is
not always being held next to the patient, but the veterinarians know its contents and take
this into practice. They say they find it useful to have a protocol, because of its helpfulness
and because it is based on the literature and contains clear instructions from a specialist.
The treatment the 32 patients presented at the UCCA eventually received is indeed mostly
the same as the treatment described in the protocol. However, it seems that in acute cases
radiographs are not always taken, while it is important to check for subcutaneous
emphysema and pneumothorax or pneumomediastinum because these signs suggest
penetrating injuries and presence of wooden foreign bodies. In chronic cases inspection of
the pharynx and larynx is not always performed. Even though this inspection usually does
not show the original wound, it could show sinuses that drain into the pharynx. The surgical
approach in both acute and chronic patients was most often explorative, unless another
approach was necessary (i.e. in the two cases where the stick had to be removed via an
incision over the stick).
The patient records in Vetware of all patients and the results from the survey held among
the patient owners show that the treatment of the patients at the UCCA is successful: most
dogs recover and do not develop any new problems in the future. However, one dog did still
have a remaining wooden foreign body in the abscess that came out on its own. Another dog
had to return to the UCCA to receive additional treatment to resolve her problems. The only
problem some owners reported the dogs did have was a thickening around the wound area.
This could very well be scar tissue. This thickening does not affect the dogs in any way. One
owner reported that his dog has some reduced lung capacity after the surgery where a stick
was removed from the thorax.
Eventually, the success rate was 77 per cent in acute cases and 79 per cent in chronic cases.
Compared with the desired success rates of respectively 90 and 80 per cent, the success in
particularly acute cases is somewhat too low. This could have several reasons. For one, the
protocol might not be sufficient. However, since the approach described in the protocol
corresponds with the approach in the literature, this is not likely the reason. Another reason
22
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
could be that not all veterinarians followed the protocol. Yet, since the patient records show
most patients were treated the way they should according to the protocol, this can not be
the (only) explanation. Thirdly, a possible explanation could be that some of the cases
presented at the UCCA were more severe than in previous studies. Furthermore, one of the
dogs with acute oropharyngeal trauma was euthanized because of the severity of the
rupture of the oesophagus and the high costs involved in treatment. The problems in this
dog might have been resolved if treatment was continued. In that case, the success rate
would have been about 85 per cent. Because this is quite an increase with just one different
outcome, it could well be that the success rates would be higher when the patient groups
were bigger. Lastly, the desired success rate is to be discussed. This success rate was based
on two studies performed in 1988 and 2000. It is to be expected that diagnostic and
operating techniques have evolved since then, and thus would ensure a higher success rate,
although treatment does not differ all that much. An increase of about five per cent in the
success rate might therefore be a bit too much. In addition, even with the best protocol
there is, if the patient’s problems are too severe, following the protocol will not be
sufficient. The protocol is based on those cases where treatment is still possible. Sometimes
euthanasia is the best solution for the patient.
In the end, the veterinarians find the protocol clear and understandable. However, it is not
clear to all veterinarians where the distinction between acute and chronic lies and that they
can use the protocol for both cases. Some veterinarians have indicated that they did not use
the protocol, since their patients had chronic problems and the protocol is for acute cases.
In addition, one veterinarian did not use the protocol during the night, because she did not
came around to it. However, it is important that a protocol is quick to read and follow, at any
time during the day or night. A decision tree might be helpful, because it gives a quick
overview and summarizes the steps that should be followed.
23
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
5
Conclusion
The aim of this research was to investigate if the current protocol used at the UCCA is
suitable for the treatment of acute and chronic oropharyngeal stick injury and whether it is
useful for the veterinarians treating these cases and to make some adjustments to the
protocol if necessary.
As it turns out, the protocol is in agreement with literature. It is practically oriented and
veterinarians find the protocol useful and understandable. However, some improvements
could be made. In a new version of the protocol both the acute and the chronic case will
have to be discussed, preferably in the form of a decision tree. This enables a quick overview
of the course of treatment and the steps that will have to be followed in both cases. Both
versions of the current UCCA protocol were used and combined with the advice described in
the literature into a new (Dutch) protocol, presented in Appendix III.
Of course it is better to prevent stick injuries than to cure them, therefore dog owners
should be advised not to let their dogs play with, chew on or carry sticks. If oropharyngeal
stick injuries do occur, it is important that the injuries are treated as soon as possible to
prevent the development of chronic complications that are more difficult to treat.
24
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
6
Acknowledgements
I would like to thank my supervisor dr. M.E. Peeters from the Department of clinical Sciences
of Companion Animals, Utrecht University, for her guidance during this research project. In
addition I would like to thank all patient owners and veterinarians who participated in the
surveys.
25
Acute and chronic oropharyngeal stick injury in dogs: What protocol should be followed?
7
References
1. White RAS, Lane JG. Pharyngeal stick penetration injuries in the dog. J Small Anim Pract.
1988;29(1):13-35.
2. Doran IP, Wright CA, Moore AH. Acute oropharyngeal and esophageal stick injury in fortyone dogs. Vet Surg. 2008;37(8):781-785.
3. Griffiths LG, Tiruneh R, Sullivan M, Reid SW. Oropharyngeal penetrating injuries in 50
dogs: A retrospective study. Vet Surg. 2000;29(5):383-388.
4. Nicholson I, Halfacree Z, Whatmough C, Mantis P, Baines S. Computed tomography as an
aid to management of chronic oropharyngeal stick injury in the dog. J Small Anim Pract.
2008;49(9):451-457.
5. Pratt JNJ, Munro EAC, Kirby BM. Osteomyelitis of the atlanto-occipital region as a sequela
to a pharyngeal stick injury. J Small Anim Pract. 1999;40(9):446-448.
6. Hartley C, McConnell JF, Doust R. Wooden orbital foreign body in a weimaraner. Vet
Ophthalmol. 2007;10(6):390-393.
7. Rayward RM. Acute onset quadriparesis as a sequela to an oropharyngeal stick injury. J
Small Anim Pract. 2002;43(7):295-298.
8. Potanas CP, Armbrust LJ, Klocke EE, Lister SA, Jimenez DA, Saltysiak KA. Ultrasonographic
and magnetic resonance imaging diagnosis of an oropharyngeal wood penetrating injury in a
dog. J Am Anim Hosp Assoc. 2011;47(1):e1-e6.
9. Peeters ME. The treatment of recurrent abscessation in the neck region of the dog,
evaluation of 35 patients. Tijdschr Diergeneeskd. 1992;117 Suppl 1:30S.
10. Peeters ME. The management of pharyngeal stick penetration injuries in dogs. European
Veterinary Conference Voorjaarsdagen 2010. 2010:227-228.
11. Fossum TW, Hedlund CS, Johnson AL, et al. Small animal surgery textbook. In: 3rd ed.
Mosby Inc; 2007:375-384.
12. Dobromylskyj MJ, Dennis R, Ladlow JF, Adams VJ. The use of magnetic resonance imaging
in the management of pharyngeal penetration injuries in dogs. J Small Anim Pract.
2008;49(2):74-79.
13. Moore AH. Sticking it to perforating injuries. Veterinary Times. 2010;40(28):30-31.
14. Plunkett SJ. Emergency procedures for the small animal veterinarian. In: Philadelphia:
W.B. Saunders; 2000:133-136.
15. Armbrust LJ, Biller DS, Radlinsky MG, Hoskinson JJ. Ultrasonographic diagnosis of foreign
bodies associated with chronic draining tracts and abscesses in dogs. Vet Radiol Ultrasound.
2003;44(1):66-70.
26
Appendix I: Klinische Richtlijn STOKTRAUMA
Inleiding
Deze klinische richtlijn betreft de opvang van honden, die een acuut stoktrauma hebben
ondergaan, waarbij de stok de mondholte, pharynx of slokdarm heeft geperforeerd. Het is van
belang om dit probleem in de acute fase adequaat te behandelen om de volgende redenen:
-
Pharynx- en slokdarmperforaties hebben een veel betere prognose als ze in de akute
fase behandeld zijn
Contaminatie en hout leiden tot ernstige ontstekingen in de hals en uiteindelijk ook in
de thorax, omdat het purulente exsudaat in de hals zal afzakken tot in het voorste
mediast.
Te volgen stappen
1. Opvang volgens het algemene spoedprotocol: besteed met name aandacht aan de
eventuele aanwezigheid van subcutaan emfyseem en aan de ademhaling. Bij ernstig
mediastinaal emfyseem kan de ademhaling belemmerd worden.
2. Maak altijd röntgenfoto’s van hals en thorax. Doel van de foto’s: inventarisatie
van vrij gas en mediastinaal emfyseem. Vrij gas in de hals betekent dat er zeker een
perforatie aanwezig is. Mediastinaal emfyseem en/of pneumothorax kan een
probleem worden bij beademing onder anesthesie. Het doel van de foto’s is NIET om
een corpus alienum op te sporen. Hout is in het algemeen niet zichtbaar op een
röntgenfoto. Is vastgesteld dat er een perforatie is, dan zal het gepenetreerde gebied in
ieder geval geopend en gedraineerd moeten worden. De perforatie plaats bevindt zich
bij dit trauma altijd hoger dan het eind van het steekkanaal. Ontstekingen zullen zich
dus ook makkelijk kunnen uitbreiden richting borstingang en thorax. Zie verder OK
aanwijzingen. Het maken van een echo in de akute fase is niet zinvol. In de hals en
keelstreek bevindt zich bij een perforatie vrij gas (lucht). Dit stoort het echo beeld.
Een klein corpus alienum zal worden gemist, een groot corpus alienum zou toch bij
halsexploratie gevonden worden.
3. Inspekteer de mond/keelholte onder anesthesie. Werkwijze: Hond in borstbuikligging. Vóór intubatie: inspekteer de volgende voorkeurslokalisaties voor
perforatief stoktrauma:
Mondbodem: links en rechts onder de tong; frenulum. Links en rechts lateraal bij de
tongaanhechting. Links en rechts laterale pharynx wand en tonsilnissen. Palatum
molle. Met laryngoscoopblad de tongbasis naar ventraal drukken en de epiglottis links
en rechts ventraal inspekteren. Vervolgens op de normale wijze intuberen, maar vóór
inbrengen van de tube beoordelen of de glottis vrij is van corpora aliena. Na intubatie
kan de larynx met het laryngoscoopblad naar ventraal worden gedrukt en is inspektie
mogelijk van: distale pharynx en proximale slokdarm. Het pharynxdak komt in beeld
wanneer de achterrand van het palatum molle met bijv. het laryngoscoopblad naar
craniaal wordt gelegd. Lokaliseer de perforatie en stel je voor hoe de stok via de weg
van de minste weerstand zich een weg gebaand heeft in de hals- en keelstreek. Als er
op bovengenoemde wijze van inspekteren geen perforatie wordt gevonden is
endoscopie van de slokdarm (en soms ook van de trachea) geïndiceerd, echter alléén
om de perforatie te lokaliseren, niet om een corpus alienum te verwijderen ( met
uitzondering van corpora aliena in de trachea, maar dat is zeer ongebruikelijk bij
stoktrauma) . Terugtrekken van hout uit het steekkanaal zal leiden tot achterblijven
van splinters. Het probleem dient vanuit de hals benaderd te worden!
27
HALSEXPLORATIE
Hond in rugligging, kussentje onder de hals, zodanig dat de trachea in een
horizontaal vlak ligt en de kop niet achterover geknikt wordt. Zonodig het voorhoofd
ook ondersteunen.
Benadering: Incisie in de ventrale mediaanlijn. Prepareren tot op de hals
musculatuur. Afhankelijk van de perforatie lokalisatie is voorstelbaar waar het
steekkanaal met evt. hout zich ongeveer zal bevinden. Zonodig kan een sonde of
steriele urine katheter via de bek in de perforatie worden geschoven ter lokalisatie.
Prepareer altijd in de lengterichting van de hals, scheidt spierbuiken zoveel mogelijk
langs hun fascie. Craniaal van het cricoid dient zeer voorzichtig geprepareerd te
worden ivm de daar aanwezige larynx- en pharynx innervatie. Werk van caudaal
(schoon) naar craniaal (vuil) tot het steekkanaal in beeld is. Leg het kanaal vervolgens
verder open en verwijder corpora aliena. Zonodig spoelen met Steriele Spoelvloeistof
met weinig druk, om contaminatie niet verder te verspreiden. Na verwijdering van
corpora aliena de hals met één of meer Penrose drains draineren (met zwaartekracht
mee, dus richting borstingang) en sluiten.
Hechten van de perforatie in de mondholte: alle perforaties waar voedsel of water
in kunnen komen als de hond slikt (dus in ieder geval alle dorsale en dorsolaterale
perforaties) hechten met Monocryl, Vicryl of PDS. Perforaties onder de tong kunnen
eventueel open gelaten worden. Er is lang instrumentarium beschikbaar (KNOGroot). Het is een kunstfout om een perforatie te hechten zonder dat een
halsexploratie en drainage uitgevoerd zijn.
Hechten van slokdarmperforaties:
Perforatie in beeld brengen door de omgevende slokdarm te teugelen en zonodig te
roteren naar ventraal. Wondranden opfrissen. Met voorgeplaatste perforerende PDS
hechtingen de slokdarm sluiten. Dubbel-lagige technieken zijn in de proximale
cervicale slokdarm meestal niet mogelijk omdat ze teveel stenose veroorzaken. Na
sluiten van de slokdarm een lokale halsspier gebruiken als “ muscular patch”. De
Penrose drain, die de hals draineert mag niet tegen de gehechte slokdarm aanliggen.
De genezing van de gehechte slokdarm verloopt niet altijd zonder complicaties. Aan
de eigenaar dient een gereserveerde prognose gegeven te worden. Om het gebied rust
te geven is het soms raadzaam om een percutane maagsonde te plaatsen via miniceliotomie, om zo de hond enige tijd niets per os te kunnen geven.
De meeste honden met stoktrauma zullen met deze richtlijn goed onderzocht en
behandeld kunnen worden, incidenteel kan men echter altijd voor verrassingen
komen te staan. Bij grote problemen sta ik graag met raad en eventueel daad
terzijde.
Dr. M.E. Peeters
Maart 2006
28
Appendix II: The management of pharyngeal stick penetration injuries in dogs 10
Note from the author: This is a translated version of the protocol used at the University
Clinic for Companion Animals and was published as a summary in the “Proceedings 2010” for
the European Veterinary Conference Voorjaarsdagen 2010.
Marijke E. Peeters, DVM, PhD, Diplomate ECVS.
Department of clinical Sciences of Companion Animals, Utrecht University, The Netherlands.
M.E.Peeters@uu.nl
Approach to the acute patient with pharyngeal stick penetration injury.
The management of acute PSPI is directed at: emergency stabilization of the patient, the
pharyngeal or esophageal perforation, the retrieval of foreign bodies, and the drainage of
the penetration tract.
1. General emergency protocol: focus on dyspnea that may develop as a result of
pharyngeal swelling or mediastinal emphysema. Provide oxygen mask. Provide IV fluids
in case of hypovolemia. Provide broad-spectrum antibiotics. Pay attention to
neurological abnormalities during the clinical examination.
2. Perform X-rays of the neck and the thoracic cavity. In most cases of pharyngeal or
esophageal lacerations there is radiographic evidence of subcutaneous emphysema.
Pneumomediastinum and/or pneumothorax are indicators for deep penetrating injuries
and may affect your anesthetic protocol. Wood does not show on X-rays!
Ultrasonography of the throat or neck is not of great use in the acute patient:
subcutaneous emphysema will mask small foreign bodies. Large foreign bodies will be
recognized anyway during surgery!
3. Under general anesthesia: Perform a thorough inspection with the dog in sternal
recumbency. Before endotracheal intubation, the following areas and structures are
visualized: sublingual area left and right to the frenulum; tongue (base, left and right
lateral pharyngeal walls and tonsillar crypts on both sides; hard and soft palate; use a
laryngoscope to visualize the epiglottis and its attachments to the pharynx and the
larynx; after inspection of the glottis, an appropriate endotracheal tube is used to secure
the airway. With the tube in place, the larynx is depressed ventrally with the help of a
laryngoscope and after rostral retraction of the soft palate the pharynx is inspected. The
cranial esophagus is inspected by using an endoscope or a longbladed laryngoscope.
When perforations are not found at this time, complete cervical esophageal endoscopy
is advised. When a piece of wood is visible in the soft tissues, withdrawal is not
recommended because of the risk of fragmentation. In all cases of perforations of the
pharyngeal or esophageal wall, surgical exploration of the neck via a ventral midline
approach is recommended.
4. Surgery: The patient is placed in dorsal recumbency with a support under the neck. Use
a ventral midline incision and explore the area of the penetration tract. If necessary, a
probe or sterile catheter may be inserted at the perforation site and will help you to
identify the direction of the penetration tract. The exploration is started in the distal
neck area and extended rostrally, working from unaffected (clean) towards affected
(dirty) tissues. The area rostral to the cricoid cartilage should be explored with great
care: the surgeon should be aware of the anatomy of the laryngeal and pharyngeal
innervations. After exposure of the penetration tract and after removing the foreign
bodies, the tract is flushed with saline, and the surgical wound is sutured over a Penrose
drain. In cases of esophageal trauma stay-sutures in the esophageal wall can be used if
29
necessary to rotate the esophagus. After local debridement, the esophageal tear is
sutured in one or two layers with PDS (cave: stenosis!). A local muscular flap can be used
as “muscular patch” to improve wound healing. A gastrostomy feeding tube is advised to
bypass the sutured esophagus.
5. Suturing of pharyngeal perforations: after performing surgical exploration and drainage
of the neck, dorsal and dorsolateral pharyngeal perforations are sutured to prevent food
and water entering the peri-pharyngeal tissues. Small sublingual perforations may be left
unsutured.
Approach to the chronic patient with pharyngeal stick penetration injury.
Cases with chronic PSPI present with a recurrent swelling or abscesses of the head or neck,
with or without a cutaneous draining sinus. The management of chronic PSPI is directed at
residual foreign body retrieval and drainage of the infected area. The principles of
presurgical inspection of the oropharyngeal cavity and the esophagus, the surgical
techniques and drainage of the infected areas, are the same as in the acutely injured
patients.
In the ideal situation, the number and localization of the foreign bodies is determined before
surgery. It is impossible to demonstrate the absence of residual stick fragments! Plain and
contrast radiography (sinography), ultrasonography, CT and MRI have all been described for
the detection of foreign bodies in chronic PSPI. The choice of the diagnostic technique
depends mainly on availability, costs, and whether extra anesthesia time (CT and MRI) is not
harmful to the patient.
Sinography is only applicable in cases with external draining sinuses. Ultrasonography is
cheap, anesthesia is not needed in most cases, and foreign bodies are easily recognized
when surrounded by exudative fluid.
Computer tomography with or without IV contrast is accurate in recognizing wood foreign
bodies. Depending on the water content of the different layers of the sticks, the foreign
bodies show a variable attenuation pattern. CT images and three-dimensional
reconstructions may aid in the planning of surgery in difficult cases.
The use of MRI in dogs with chronic PSPI has been evaluated in small series of cases. MRI
was found to be very helpful in localizing wooden foreign bodies but other types of plant
material (grass seeds) were less apparent on MRI images.
References
1. White RAS, Lane JG. Pharyngeal stick penetration injuries in the dog. J small Anim Pract 1988;29:13-35
2. Griffiths LG, Tiruneh R, Sullivan M, Reid SWJ. Oropharyngeal penetrating injuries in 50 dogs: a retrospective
study. Vet Surg 2000;29:383-388
3. Dobromylskyj MJ, Dennis R, Ladlow JF, Adams VJ. The use of magnetic resonance imaging in the
management of pharyngeal penetration injuries in dogs. J Small Anim Pract 2008;49:74-79
4. Nicholson I, Halfacree Z, Whatmough C, Mantis P, Baines S. Computed tomography as an aid to
management of chronic oropharyngeal stick injury in the dog. J Small Anim Pract 2008;49:451-457
5. Doran IP, Wright CA, Moore AH. Acute oropharyngeal and esophageal stick injury in forty-one dogs. Vet Surg
2008;37:781-785
30
Appendix III: Voorstel protocol voor de behandeling van stoktrauma
Inleiding
Dit protocol is gericht op de behandeling van honden met (mogelijk) oropharyngeaal
stoktrauma. Onopgemerkt trauma of onsuccesvolle behandeling van de acute patiënt kan
leiden tot chronische problemen die lastig te verhelpen zijn. Vandaar dat snelle, adequate
behandeling zo belangrijk is.
Tijdens het gebruik van dit protocol is het belangrijk te realiseren dat het gaat om richtlijnen
voor de behandeling. Elk geval is anders en kan een andere, afwijkende, aanpak vereisen.
In geval van twijfel, onduidelijkheden of problemen is het raadzaam een specialist te
consulteren.
Aanpak
Allereerst is het belangrijk onderscheid te maken tussen acuut en chronisch stoktrauma:
- Acuut stoktrauma: <7 dagen sinds stoktrauma
o Veel voorkomende verschijnselen: moeite met slikken, speekselvloed (mogelijk met
bijmenging van bloed), pijn van de bek, sloom, verminderde eetlust/anorexie,
zwelling van de nekregio, dyspneu, shock
- Chronisch stoktrauma: >7 dagen sinds stoktrauma (kan weken tot maanden zijn!)
o Veel voorkomende verschijnselen: abcesvorming, fistels
Acuut en chronisch stoktrauma vereisen een verschillende aanpak en zullen dus apart
besproken worden.
De aanpak is ook verwerkt tot een beslisboom, zodat er een snel overzicht van de
behandeling van patiënten met stoktrauma verkregen kan worden.
Acuut Stoktrauma
Adequate behandeling van de acute patiënt is belangrijk omdat:
 Pharynx- en slokdarmperforaties een veel betere prognose hebben als ze in de acute
fase behandeld zijn.
 Contaminatie en hout tot ernstige ontstekingen in de hals en uiteindelijk ook in de
thorax leiden, omdat het purulente exsudaat in de hals zal afzakken tot in het voorste
mediast.
De behandeling is dan ook gericht op stabilisatie van de patiënt, de pharyngeale of
oesophageale perforatie, het verwijderen van achtergebleven vreemd materiaal
(houtsplinters) en drainage van het steekkanaal.
Te volgen stappen
1. Opvang volgens het algemene spoedprotocol.
- Besteed met name aandacht aan mogelijke obstructies van de luchtweg, de
ademhaling (o.a. tekenen van dyspneu), bloedingen, subcutaan en/of mediastinaal
emfyseem en neurologische afwijkingen tijdens het klinisch onderzoek.
- Zorg voor een zuurstofmasker, dien een infuus toe in geval van hypovolemie en geef
de patiënt breedspectrum antibiotica.
- Voorkom voedsel- en waterinname om de kans op contaminatie van het mediast te
voorkomen.
31
2. Maak altijd röntgenfoto’s van hals en thorax.
- Doel: inventarisatie van vrij gas en mediastinaal emfyseem en/of pneumothorax.
Vrij gas in de hals betekent dat er zeker een perforatie aanwezig is. Mediastinaal
emfyseem en/of pneumothorax kan een probleem worden bij beademing onder
anesthesie.
- Veel voorkomende verschijnselen: subcutaan emfyseem, verlies van structuur van
weke delen, laceraties en cellulitis.
- Hout is in het algemeen niet zichtbaar op een röntgenfoto.
- Het maken van een echo in de acute fase is niet zinvol, omdat zich bij een perforatie
vrij gas bevindt in de hals en keelstreek. Dit stoort het echobeeld. Een klein corpus
alienum zal worden gemist, een groot corpus alienum zal bij halsexploratie toch
gevonden worden.
3. Inspectie van de mond/keelholte onder anesthesie.
- Bij de hond in borstbuikligging.
- Voor intubatie: inspecteer de volgende voorkeurslocaties voor perforatief
stoktrauma:
o Harde en zachte gehemelte
o Links en rechts onder de tong
o Frenulum
o Links en rechts lateraal bij de tongaanhechting
o Links en rechts laterale pharynxwand
o Tonsillen
o Links en rechts ventraal de epiglottis, door met een laryngoscoopblad de
tongbasis naar ventraal te drukken
o Beoordelen of de glottis vrij is van corpora aliena
- Na intubatie: inspectie van de distale pharynx en proximale slokdarm door de larynx
met het laryngoscoopblad naar ventraal te drukken.
o Het pharynxdak komt in beeld wanneer de achterrand van het palatum molle
met bijv. het laryngoscoopblad naar craniaal wordt gelegd.
- Lokaliseer de perforatie en stel je voor hoe de stok via de weg van de minste
weerstand zich een weg gebaand heeft in de hals- en keelstreek. De perforatieplaats
bevindt zich altijd hoger dan het eind van het steekkanaal.
- Probeer de ernst van de wond in te schatten en te ontdekken of de oesophagus ook
bij de verwondingen is betrokken. Penetratie van de oesophagus heeft een meer
gereserveerde prognose.
- Alle pharyngeale wonden moeten chirurgisch geëxploreerd worden via de hals en
eventueel aanwezige corpora aliena moeten worden verwijderd.
4. Indien er tijdens stap 4 geen perforatie wordt gevonden is endoscopie van de
slokdarm (en soms trachea) geïndiceerd.
- Endoscopie alleen om de perforatie te lokaliseren, niet om een corpus alienum te
verwijderen (met uitzondering van corpora aliena in de trachea, maar dat is zeer
ongebruikelijk bij stoktrauma). Terugtrekken van hout uit het steekkanaal zal leiden
tot achterblijven van splinters. Het probleem dient vanuit de hals benaderd te
worden.
5. Exploratie van het steekkanaal via de hals (en evt. via de bek)
- Bij de hond in rugligging met een kussentje onder de hals, zodanig dat de trachea in
een horizontaal vlak ligt en de kop niet achterover geknikt wordt. Zonodig het hoofd
ook ondersteunen.
32
-
-
-
-
Benadering via een incisie in de ventrale mediaanlijn. Prepareren tot op de
halsmusculatuur.
o Op deze manier kunnen belangrijke neurovasculaire structuren van de hals
worden geïdentificeerd en is er toegang tot beide kanten van de hals om de
weefsels te exploreren.
o Rostrale pharyngeale wonden en wonden onder de tong moeten mogelijk zowel
vanuit de bek benaderd worden (vanwege de anatomische beperkingen die de
ventrale benadering met zich meebrengt) als via exploratie van de halsregio.
Overslaan van deze exploratie kan er toe leiden dat stukken stok worden gemist,
de uitgang van het steekkanaal ligt immers lager dan de ingang en stukken stok
kunnen zich dus ook in de hals bevinden.
Afhankelijk van de perforatie lokalisatie is voorstelbaar waar het steekkanaal met
evt. hout zich ongeveer zal bevinden. Zonodig kan een sonde of steriele urine
katheter via de bek in de perforatie worden geschoven ter lokalisatie.
Prepareer altijd in de lengterichting van de hals, scheidt spierbuiken zoveel mogelijk
langs hun fascie. Craniaal van het cricoid dient zeer voorzichtig geprepareerd te
worden i.v.m. de daar aanwezige larynx- en pharynxinnervatie.
Werk van caudaal (schoon) naar craniaal (vuil) tot het steekkanaal in beeld is. Leg
het kanaal vervolgens verder open en verwijder corpora aliena. Zonodig spoelen met
steriele spoelvloeistof met weinig druk, om contaminatie niet verder te verspreiden.
6. Hechten van slokdarmperforaties.
- Perforatie in beeld brengen door de omgevende slokdarm te teugelen en zonodig te
roteren naar ventraal.
- Wondranden opfrissen.
- Met voorgeplaatste perforerende PDS hechtingen de slokdarm sluiten. Dubbellagige
technieken zijn in de proximale cervicale slokdarm meestal niet mogelijk omdat ze
teveel stenose veroorzaken.
- Na sluiten van de slokdarm een lokale halsspier gebruiken als “muscular patch”.
- De drain die de hals draineert mag niet tegen de gehechte slokdarm aanliggen.
- De genezing van de gehechte slokdarm verloopt niet altijd zonder complicaties. Aan
de eigenaar dient een gereserveerde prognose gegeven te worden.
7. Drainage.
- De hals met één of meer Penrose drains draineren (met zwaartekracht mee, dus
richting borstingang).
- De drains via een aparte incisie naast de initiële incisie uit laten komen.
- De drains kunnen verwijderd worden wanneer de wond niet meer productief is.
8. Hechten van de perforatie in de mondholte.
- Alle perforaties waar voedsel of water in kan komen als de hond slikt (dus in ieder
geval alle dorsale en dorsolaterale perforaties) hechten met Monocryl, Vicryl of PDS.
- Perforaties onder de tong kunnen eventueel open gelaten worden.
- Het is een kunstfout om een perforatie te hechten zonder dat een halsexploratie en
drainage uitgevoerd zijn.
9. Post-operatieve therapie.
- Om het operatiegebied rust te geven is het soms raadzaam om een percutane
maagsonde te plaatsen via mini-celiotomie, om zo de hond enige tijd niets per os te
kunnen geven.
o Vooral in gevallen van matige tot ernstige schade aan de oesophagus.
- Analgesie (bijv. opiaten of NSAID’s).
- Antibiotica indien geïndiceerd (bij erg vieze wonden en wanneer een corpus alienum
verwijdert is).
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Chronisch Stoktrauma
Chronisch stoktrauma is lastiger te diagnosticeren en behandelen dan acuut stoktrauma.
Problemen kunnen daardoor weken, maanden en zelfs jaren bestaan. De behandeling is
gericht op het verwijderen van achtergebleven corpora aliena en drainage van het ontstoken
gebied.
Te volgen stappen
1. Algemeen lichamelijk onderzoek en onderzoek diktes.
2. Probeer de oorzaak voor de abcesvorming en fistels te achterhalen.
- Mogelijke oorzaken: corpus alienum, chronische aandoening van het oor, infectie
met Actinomyces species.
- Met behulp van diagnostische beeldvorming en bacteriologische kweek
(Actinomyces spp.)
3. Diagnostische beeldvorming.
- Achterhalen van de oorzaak van de problemen.
- Bepalen van aanwezigheid, aantal en lokalisatie van achtergebleven corpora aliena.
- Radiografie, sinografie/fistulografie, echografie, MRI en CT zijn beschreven als
mogelijke diagnostische technieken. Hun voor- en nadelen staan beschreven in de
onderstaande tabel.
- De keuze hangt af van beschikbaarheid, kosten, voordelen en eventueel risico voor
de patiënt (bijv. extra anesthesietijd).
Diagnostiek
Radiografie
Voordelen
Relatief goedkoop; beschikbaar
Sinografie /
fistulografie
Kan gebruikt worden om achtergebleven
radiolucente CA te onderzoeken; bruikbaar als
fistel aanwezig is
Echografie
Kan CA detecteren; informeert over grootte,
vorm en locatie; informeert over mate van het
probleem; behulpzaam bij planning van de
operatie; vereist geen of slechts lichte sedatie;
beschikbaar; relatief goedkoop
MRI
Behulpzaam bij planning van de operatie;
informeert over mate en locatie van aangedane
structuren; meest effectief in bepalen van mate
van weke delen ontsteking; informeert over
aanwezigheid, grootte, vorm en locatie van CA
CT
Behulpzaam bij planning van de operatie;
informeert over mate en locatie van aangedane
structuren; geeft meest nauwkeurige
informatie over aanwezigheid, vorm, grootte
en locatie van CA; minder duur dan MRI;
kortere anesthesietijd dan MRI
CA = corpora aliena
Nadelen
Houten CA zijn niet zichtbaar; afwijkingen
die voorkomen in het acute geval zijn vaak al
opgelost; niet echt nuttig bij chronische
gevallen
Afhankelijk van de aanwezigheid van een
fistel; CA zelden gelokaliseerd.
Ervaring met echografie en te onderzoeken
regio noodzakelijk; mogelijk vals positieve
diagnose t.g.v. botfragmenten en
mineralisatie; aanwezige lucht en bot kan
het onderzoek verstoren.
Niet echt bruikbaar bij het bepalen van het
aantal houten CA; niet in staat andere typen
plantenmateriaal te lokaliseren; vereist
lange sedatie of anesthesie; relatief duur.
Slechte differentiatie tussen ontstekingsreactie en weefsel er omheen; verreist
sedatie of anesthesie; relatief duur.
4. Stopzetten van de (eventuele) behandeling met antibiotica en/of steroïden
- Deze medicijnen onderdrukken de suppuratieve reactie en veroorzaken vorming van
bindweefsel rond het corpus alienum, waardoor deze moeilijker te lokaliseren is.
- Stopzetten ruim voordat de operatie plaats zal vinden.
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-
Totdat er zich weer wat vloeistof (pus) heeft gevormd in het abces. Bij herhaalde
diagnostische beeldvorming zal vervolgens mogelijk het corpus alienum wel
aangetoond kunnen worden.
5. Inspectie van de mond/keelholte onder anesthesie.
- Zoals beschreven bij acuut stoktrauma.
- De originele wond is vaak niet te vinden. Indien deze wel gevonden wordt geeft dit
informatie over het pad dat het corpus alienum afgelegd zou kunnen hebben.
- Controleer of er fistels in de bek uitkomen.
6. Halsexploratie.
- Zoals beschreven bij acuut stoktrauma.
- Exploreer de fistels via longitudinale incisies. Verwijder aanwezige corpora aliena en
fris de belijning van de fistels op met behulp van gaaskompressen.
- Open en exploreer alle abcessen. Verwijder aanwezige corpora aliena en fris de
belijning van het abcessen op met behulp van gaaskompressen.
- Zonodig spoelen met steriele spoelvloeistof met weinig druk, om contaminatie niet
verder te verspreiden.
7. Drainage.
- Zoals beschreven bij acuut stoktrauma.
8. Post-operatieve therapie.
- Vloeistoftherapie tot orale voeding wordt hervat.
- Analgesie (bijv. opiaten of NSAID’s).
- Antibiotica indien geïndiceerd (bij erg vieze wonden en wanneer een corpus alienum
verwijdert is).
35
Oropharyngeaal Stoktrauma
Hoe lang geleden is het stoktrauma opgetreden?
<7 dagen geleden
>7 dagen geleden
Acuut
Chronisch
Algemeen Spoedprotocol
- let op: luchtwegobstructies, afwijkende ademhaling, bloedingen,
subcutaan en/of mediastinaal emfyseem, neurologische afwijkingen
- zorg voor: zuurstofmasker, infuus bij hypovolemie, breedspectrum AB
Algemeen Onderzoek + Onderzoek Diktes
Probeer de oorzaak van de abcessen en fistels te achterhalen
- CA, chronische aandoening oor, infectie met Actinomyces species
Röntgenfoto hals + thorax
- bepaal de evt. aanwezigheid van vrij gas, mediastinaal emfyseem
en/of pneumothorax
Diagnostische Beeldvorming
- echo/CT/MRI
- achterhaal de oorzaak van de problemen
- bepaal de aanwezigheid, het aantal en de lokalisatie van evt.
achtergebleven CA
Wordt de hond op dit moment behandeld met AB en/of steroïden?
Ja
Herhaal
Pre-operatief
Nee
Stopzetten ruim voor aanvang van chirurgie
Mond/keelinspectie onder anesthesie
- hond in borstligging
- voor intubatie: inspecteer de voorkeurslocaties van perforatief stoktrauma
- na intubatie: inspecteer de distale pharynx en proximale slokdarm
Acuut
Chronisch
Perforatie gevonden?
Ja
Nee
Endoscopie
- perforatie lokaliseren
Halsexploratie
- hond in rugligging
- incisie in ventrale mediaanlijn
Acuut
Chronisch
Steekkanaal in beeld brengen, openen en CA verwijderen
Fistels en abcessen exploreren, CA verwijderen, belijning opfrissen
Zonodig spoelen met steriele spoelvloeistof
Acuut
Chronisch
Slokdarmperforatie?
Ja
Nee
Hechten
- eerst wondranden opfrissen
- met voorgeplaatste perforerende PDS hechtingen
- lokale halsspier gebruiken als muscular patch
Drainage
- met 1 of meer Penrose drains
Perforatie in de mondholte waar voedsel/water in kan komen bij slikken?
Ja
Hechten
- met monocryl/vicryl/PDS
Nee
Sluiten
Post-operatieve therapie
- analgesie
- antibiotica indien geïndiceerd (bij erg vieze wonden en wanneer een CA verwijdert is)
- bij acuut: evt. percutane maagsonde
- bij chronisch: vloeistoftherapie
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