PSOM Questions

BB has been doing a lot of head rubbing, pushing her head against the ground while digging at the floor and recently yelping when touched around the ears. The Vet suspected allergies/ears or SM. Due to the high potential for SM we decided to go to the neurologist and have an MRI. She has Chaiari Type I Malformation which the doctor says is not unusual with Cavaliers and not likely the cause of BB's pain. She has a high amount of fluid in both ears but it is much worse in the right one.

We have now been referred to a dermatologist in Charlotte, NC which the doctor said he felt was very good with the treatment of PSOM issues but it can take a while to get in sometimes (not sure what a while is...they are not open over the weekend). BB has been prescribed 100mg Gabapentin and 50mg Tramadol both 2x a day. This has stopped the floor digging and head rubbing on the furniture so far this morning. I can tell it helps because this AM BB started with the head rubbing and stopped after getting her meds this AM.

It it seems very likely that with her discomfort and pain we will do the surgery. But now for my questions...
-how can you tell if the doctor is good?
-is the high rate of reoccurrence due to the doctor?
-do they place tubes in the ears to keep the fluid out? (Read this somewhere)
-should these meds be making her so tired and after the surgery will she need to continue with the pain meds?
-should I limit her activities? (calling the neurologist about this too)
-what is the normal treatment? Are there options or is there only one method of treatment?
-is this something caused by poor breeder practices?

sorry for the long post but I have read everything possible and just trying to get as much information as possible before the appointment which I am hoping to get scheduled ASAP.

Can't answer any queries about PSOM, but it is normal for gabapentin to cause drowsiness; it usually wears off after a couple of weeks. CM can cause pain on its own, especially if the slower circulation of the cerebral-spinal fluid causes dilated ventricles, which can produce headaches (neurologists have only recognised this in the last few years, and not all vets are aware of it - some still think that it is SM alone that causes pain). I would presume that after the operation you will have a clearer idea of whether BB's head rubbing was caused solely by her PSOM, or whether it was related to her CM and adjust her meds accordingly.

Others will be able to tell you more about PSOM.

Kate, Oliver and Aled

BeBe said:

... But now for my questions...
-how can you tell if the doctor is good?

Click to expand...

Good at what? PSOM surgery? I think probably the best would be Dr. Lynette Cole at Ohio State. She is not a neurologist; she specializes in dermatology. I think that veterinary dermatologists are the most qualified to perform this procedure. It is in their arena, so to speak. But neurologists can do it, too.

BeBe said:

-is the high rate of reoccurrence due to the doctor?

Click to expand...

I cannot imagine that it is. This procedure simply removes the mucus plug. It does not deal with the cause of the build-up of mucus.

BeBe said:

-do they place tubes in the ears to keep the fluid out? (Read this somewhere)

Click to expand...

The use of tympanostomy tubes has been tried; they are discussed here: http://www.cavalierhealth.org/psom.htm#Treatment I am not aware of any additional information about them that has been published.

BeBe said:

-should these meds be making her so tired and after the surgery will she need to continue with the pain meds?

Click to expand...

I think the pain meds can have that side effect. I imagine that immediately after surgery, pain meds will be prescribed for a short time. N-Acetyl-L-Cysteine (NAC), a mucolytic -- mucus thinning agent or expectorant -- has been prescribed following PSOM surgeries.

BeBe said:

-should I limit her activities? (calling the neurologist about this too)

Click to expand...

I don't know.

BeBe said:

-what is the normal treatment? Are there options or is there only one method of treatment?

Click to expand...

The most common treatment is the myringotomy. Here is a link to a YouTube video of that procedure.
https://www.youtube.com/watch?v=nu0i2EvIaU8&feature=youtu.be
An alternative surgery is a ventral bulla osteotomy, which involves making an incision on the under side of the neck behind the jaw bone. The auditory bulla, a hollow bony sheath that encloses parts of the middle ear, then is exposed and is opened. Here is a link to a snapshot of that procedure. http://www.cavalierhealth.org/images/bulla.jpg

BeBe said:

-is this something caused by poor breeder practices?

Click to expand...

I cannot imagine that it is. My layman's theory is that it is a consequence of what I call the accordion effect upon the cavalier breed's skull as a result of the breed being created by elongating the very short muzzle of the English toy spaniel (King Charles spaniel). First the toy spaniels were produced by selecting breeding stock with short muzzles to create the English toy spaniel. Then, beginning in 1927, breeders selected English toys with longer muzzles to create the cavalier King Charles spaniel. So we start with a long muzzle, then shorten it, and then elongate it again. Hence, the accordion effect.

It definitely is due in part to the fact that the CKCS is brachycephalic, but a lot of other breeds are, too, and they don't have PSOM. So there must be something relatively unique to the cavalier that has brought about PSOM.

I think that veterinary dermatologists are the most qualified to perform this procedure. It is in their arena, so to speak. But neurologists can do it, too.

Click to expand...

Veterinary dermatologists perform the procedure in our area, too.

My cavalier, Harlow, actually had partial facial paralysis from her PSOM. She had had some symptoms for a while: not being as active and playful as she used to be, reluctance to chew her kibble (which we just attributed to her being picky), and lots of face rubbing and ear/face scratching. One day we found her hiding in the closet, drooling in obvious pain, and half her face was hanging not quite right. She was 2 1/2 at the time. The MRI showed CM and PSOM, but no SM. We did a myringotomy at the same time as the MRI. After the myringotomy, she was much better. We also put her on gabapentin at the time because she also has some symptoms from her CM (yelping when touched under her armpits, scooting, difficulty jumping). I suspect the gabapentin also helps with the residual numbness and nerve damage from the PSOM. Although her tongue hangs out of her mouth now and she can't close her eyes to blink or sleep, her face no longer has the droopy look and she's as playful as she was as a puppy. And she wolfs down her dry kibble now in no time at all! We used to have to play games to get her to eat it, and it breaks my heart to think that all that time she was in too much pain to chew

We did have to repeat the procedure two years later, because she was again scratching her ears a lot. She got it done at the same time as a teeth cleaning and her neurologist was fine with doing it without an MRI beforehand. She again found mucous in both of her ears. She's now 6 1/2 and I think it's time for another myringotomy. For whatever reason, she hasn't had the facial paralysis return even though the mucous has. Maybe because we're no longer letting it accumulate as much.

After seeing what the PSOM did to poor little Harlow, I personally would not hesitate to do a myringotomy. Especially if you find it while the dog is already anesthetized for an MRI, and can do it as part of the same procedure, I figure you might as well.

Thank you for sharing your experience, how awful! The neurologist in our area does not do the myringotomy and we are waiting to get into the Dermatology and Ear specialist. It is my hope they will do the surgery the same day they see her, BeBe is on Gabapentin until the appointment. It is really terrible to see the impact of PSOM but good to hear success with the surgery...