"Any good medication for this dog?" the mother had medication from the first two vets but the problem of snoring and pus leaking from the upper and lower eyelids of the left eye remained unresolved. It would have been so easy to give some medication but that would not resolve the problem.

I diagnosed the persistent eye problem ad due to several large abscesses below and above the skin of eyelids of the left eye. There was a slight subcutaneous swelling above the upper eyelid but this was not the main problem.

Anaesthesia was most risky in such an old dog and death on the operating table would be highly likely. So the owners wanted some good drugs. This would not cure the problem as lancing the abscesses and excision of the lower eyelid swelling (tumour) would be the best approach. The only approach. But the dog might die on the operating table. So there was an impasse. I suggested blood test to screen the dog's health. It was normal. So sedation with domitor and ketamine at low doses and isoflurane gas by tube were given. I used electro-surgery to excise a 4-cm cut below the lower eyelid and part of the upper eyelid to drain out the voluminous amount of pus. A speedy surgery was done as this dog could die any minute, being so thin and old.

In theory, I should not stitch up the 4-cum cut below the left eye so that any remaining pus and dead cells would drain out. But the dog must go home and not be hospitalised for a few days to get the septic wound clean, I decided to stitch up this large gap after excision of the pus. A video of the dog and the surgery is at:

http://www.youtube.com/watch?feature=player_detailpage&v=mFeMDlLJvSo#t=281s

In my follow up a few days later, the mother was most pleased as the dog no longer snored. However 2 months later, on or around Feb 8, 2013, the dog came back again. The dog was snoring and the mother had pressed out thick yellow pus from the lower eyelid skin and conjunctiva with swabs.

"What are the chances of survival under anaesthesia?" the adult son asked me over the phone as his mother was at my surgery wanting a solution to the snoring and now anorexia (loss of appetite).

"50:50", I said.

"That's not good enough," he did not consent to the anaesthesia.

This time, the upper eyelid no longer seeps out pus. Only the inside of the lower eyelid and the skin below it. I could see that the conjunctiva of the lower eyelid was much swollen being impregnated with pus. The mother pressed the lower eyelid and pus oozed out from this conjunctiva and a hole in the medial canthus of the left eye.

"What's the cause?" the son asked me.

"There is a thick band of pus on the left side of the gum, nearer to the nose, as if it had leaked out from inside the nasal septum near the extracted canine tooth area. The pale gum of 2x1 cm near the upper premolar 4 revealed that there could be some pus leaking earlier and removed by the dog's tongue. From my veterinary anatomy knowledge, there was a recurrent "carnaissal tooth abscess". The bacteria lodged inside the nasal sinuses.

"So the vet did not do a good job as all the teeth had been extracted (to drain out the pus) earlier," the son said. It was very difficult to explain to him that not all diseases of carnaissal tooth abscesses can be cured at one treatment. The vet could give some reasons like the resistance of bacteria. What the owner wanted was to get the problem resolved, not a long explanation of likely causes as my young associate vet would communicate if he had handled this case.

There would be more money to be spent and this would be one reason that the owner is unhappy with a need for further treatment. This cannot be helped. I have an 8-year-old car leaking radiator water and had sent for some 5 workshop sessions with new radiator and piping costing me over a few thousand dollars. The car still needs topping up of radiator water every 2-3 weeks now. It is like this dog. It still snored.

Cars can get the parts replaced. Dogs can't get a new nasal sinus or new left eye and surrounding skin area replaced even if the owner has lots of money.

This was the situation I was in. Allegations of veterinary incompetence could be nasty if both parties get heated up. The interest of the dog would then be ignored. Unfortunately, more money must be spent on another surgery to lance the abscess. Anaesthesia could just kill this old dog and surgery which would not guarantee a cure at one treatment. So, what should I do? Pass the case to another vet?

I said to the mother: "Old dogs are like old cars. Many breakdown problems requiring lots of money for repairs and maintenance. There is a need for anaesthesia but at a minimum to reduce the risk of death.

"No drugs would cure this snoring as the pus must be drained off. You can see the sticky pus below the lip at the left side of the mouth at the gum. You press out pus daily from the lower eyelid. Now the dog is not eating anymore. He will die from starvation. So, the only choice is surgical drainage of the pus."

She had Hobson's choice. Two months had passed. One month without snoring. The dog ate. Now, the dog snored and did not eat. She gave her consent for anaesthesia. Dr Daniel assisted me. I gave the dog a dose of 5% isoflurane gas by mask. He was knocked out in a short time as he was in poor health. The judgment of how long and how much isoflurane gas to use is based on observation and experience. It is hard to describe. A snoring dog not eating is the worst type of anaesthetic patient. Surgical anaesthesia in the ideal situation was not possible as the less isoflurane the better on this old companion of the mother. At one stage, the dog woke up and whined as I pressed out the pus from the lower eyelid. Lots of blood and pus. Speedy handwork was essential. A sound knowledge of veterinary anatomy of this facial area, nimbleness and experience were requisites for this operation. After all, what the owner wanted was first and foremost, a dog alive at the end of an operation.   

An IV dextrose saline drip for 30 minutes was given first. The owner wanted the dog home and so there was no time to give more IV drip overnight. I used the dental forceps to break down the gum level at the left upper premolar 4, the gap where the left upper canine tooth had been located, made a 4-cm skin incision in the lower eyelid skin and no more stitching this time, an incision into the swollen lower conjunctiva. Also I made a 1-cm incision into the left forehead swelling above the upper eyelid and thick  pus seeped out. I pressed out as much pus as possible. The mother would do the nursing. The dog went home on Feb 8, 2013. Today is Feb 15, 2013. I will follow up soon as to whether the snoring would still be present. It disappeared for around 4 weeks after the first operation but the owners did not follow up with me when the pus returned, preferring self treatment of expressing the pus from the lower eyelid of the left eye. So the left forehead swelling above the upper eyelid increased in size to 8 cm x.3 cm x 1 cm. That was pus inside when I lanced it.

Regular dental check up early in the dog's life would have prevented this problem of recurring carnaissal tooth abscess with pus spreading to the nasal sinuses and the forehead muscles and under the skin.  A dog needs regular check up but most Singaporean dog owners don't bother even when loose decayed teeth drop out and bad breaths are tolerated.          

Updates will be at this webpage:
http://www.bekindtopets.com/dogs/20130215old_dog_eye_bag_toapayohvets.htm