Clinical and surgical management of complete cleft palate in a Siberian Husky dog - case report

[Manejo clínico e cirúrgico da fenda palatina completa em cão da raça Husky Siberiano - relato de caso]

ABSTRACT

Congenital cleft palate is the most described malformation in dogs, especially in purebred puppies. It is characterized by abnormal communication between the oral and nasal cavities through an opening in the palate, which can cause milk aspiration, pneumonia, inadequate breastfeeding, neonatal triad, failure to gain weight and death. The objective of this report was to describe the clinical and surgical management of a neonatal Siberian Husky puppy ​​with congenital cleft palate, highlighting the importance of orogastric probing for neonatal survival, as well as surgical correction for the patient's quality of life. Orogastric tube feeding was performed during the first four months of age, and after this period, the surgical procedure to close the palate was performed. The management of the orogastric tube proved to be effective, with adequate development of the puppy (constant weight gain), a reduced risk of neonatal triad and milk aspiration, good acceptance by the patient, and easy management for owners. The waiting time for cleft palate surgery, performed at four months of age, proved to be essential to avoid reopening the cleft.

Keyword:
canine neonatology; congenital malformation; palatoschisis; puppy; orogastric tube

RESUMO

A fenda palatina congênita é a malformação mais comumente descrita em cães, principalmente em filhotes de raças puras. É caracterizada por uma comunicação anormal entre a cavidade oral e nasal por meio de uma abertura no palato, podendo levar à aspiração do leite, pneumonia, amamentação inadequada, tríade neonatal, falha no ganho de peso e ao óbito. O objetivo deste relato foi descrever o manejo clínico e cirúrgico de um cão neonato da raça Husky Siberiano com fenda palatina congênita, evidenciando-se a importância da sondagem orogástrica para a sobrevivência neonatal bem como da correção cirúrgica para a qualidade de vida do paciente. Foi realizada alimentação por sondagem orogástrica durante os primeiros quatro meses de idade, e, após esse período, o procedimento cirúrgico de fechamento do palato foi realizado. O manejo da sondagem orogástrica demonstrou ser eficaz, observando-se desenvolvimento adequado do filhote (ganho de peso constante), redução dos riscos de tríade neonatal e aspiração do leite, e boa aceitação pelo paciente. Além disso, foi considerado um manejo de fácil realização pelos tutores. O tempo de espera para a cirurgia da fenda palatina, realizada aos quatro meses de idade, demonstrou ser essencial para evitar reabertura da fenda.

Palavras-chave:
neonatologia canina; malformação congênita; palatosquise; filhote; sondagem orogástrica

INTRODUCTION

The cleft palate (palatoschisis) is the most common malformation found in neonatal puppies, especially in purebred animals (approximately 84% of cases). The incidence corresponds to 3%, so that, for every 33 dogs born, one will manifest this congenital defect (Pereira et al., 2019).

It is characterized by an opening in the hard and/or soft palate, which allows communication between the oral and nasal cavities (Macário et al., 2021). This opening is present in the embryo, and its closure must occur between the 25th and 28th days of gestation (Warzee and Bellah, 2011); however, genetic or teratogenic factors (e.g., the administration of drugs, such as tetracyclines and corticosteroids, excess vitamin A, folic acid deficiency, and infectious diseases, among others), can interfere with the closure of the palate during embryonic development (Casal, 2016; Pereira et al., 2019). Furthermore, factors such as consanguinity (endogamy) lead to the loss of genetic variability and increased homozygosity, which can increase the risk of malformations (Pereira et al., 2022).

The cleft palate is considered partial when it affects the hard or soft palate and complete when it affects both palates (Hette and Rahal, 2004), as well as being central or unilateral in the palate (Moura and Pimpão, 2017). The main consequence of this malformation is the risk of milk passing into the nasal cavity and consequently aspiration, which can lead to pneumonia and death (Lourenço, 2023). The main clinical signs observed include the exit of milk through the nostril, choking, difficulty in breastfeeding (due to failure of the vacuum during sucking) and consequent neonatal triad (hypoglycemia, hypothermia and dehydration), weak or absent sucking reflex, weight loss and growth retardation. Diagnosis is made by direct inspection of the oral cavity (Pereira et al., 2019; Lourenço, 2023).

Surgical correction is the definitive treatment, which must be carried out between four and six months of age. Until this moment, feeding management via an orogastric tube is indicated until the puppy reaches an adequate size of the oral cavity that allows surgery (Davidson et al., 2014; Lourenço, 2023). When surgery is performed before the recommended age, there is a high risk of palatal reopening and delayed maxillary growth (Fiani et al., 2016). Despite being a common malformation in dogs, there are few reports in veterinary literature about the correct management of this malformation (Warzee and Bellah, 2011). Therefore, the objective of this report was to describe the neonatal clinical management of cleft palate through orogastric probing and subsequent surgical treatment in a Siberian Husky dog.

CASUISTRY

A three-day-old female Siberian Husky neonatal dog (Fig. 1) with a history of respiratory discomfort and unresponsiveness to stimuli (stupor state) for approximately four hours was treated at a veterinary hospital in São Paulo, Brazil. According to clinical history, the newborn was the smallest of the litter, and on the day of care, he was isolated from the other puppies. On physical examination, the patient presented a neonatal triad (hypothermia of 32°C, hypoglycemia of 10mg/dL and dehydration), an absent sucking reflex, a weight of 350 grams, a heart rate of 188 bpm, a respiratory rate of 16 mpm, cyanosis, dyspnea and crepitus on lung auscultation. Upon inspection of the oral cavity, a central opening was observed in the hard and soft palate, with communication between the oral and nasal cavities along its entire length and approximately 2 cm wide, indicating that the congenital malformation was a complete cleft palate (Fig. 2).

Emergency treatment consisted of oxygen therapy via mask, neonatal warming (using a thermal mattress and gloves with warm water), and intravenous fluid therapy with 5% glucose solution (2 ml per 100 grams of weight). After the patient was stabilized and the clinical parameters were normalized, which revealed eupnea, pink mucous membranes, normal hydration, a heart rate of 200 bpm, a respiratory rate of 24mpm, a blood glucose level of 100 mg/dL and a temperature of 37.5°C, additional tests were performed. The blood count and blood gas analysis results were within normal and reference standards for his age. The chest radiographic examination revealed a slight pattern of opacification in the left cranial lobe, indicating aspiration pneumonia.

Figure 1
Three-day-old newborn during the first visit.

Figure 2
Complete cleft palate in a neonatal dog.

After the neonate became normothermic, feeding was initiated via orogastric tube (using a #6 urethral tube) (Fig. 3), following the management methods described by Peterson e Kutzler (2011) and Fuchs et al. (2024). Video 1 (Access link: https://drive.google.com/file/d/1JDaKomXy9F8lOLAPSxJOC7DBAs7v5rEF/view?usp=drivesdk) demonstrating how to perform orogastric tube feeding in a patient with cleft palate. With the newborn in lateral decubitus, the tube was measured from the last rib to the tip of the nose and marked with tape at this limit. The mark guides the tube insertion length correctly into the stomach, preventing the tube from kinking in the gastrointestinal tract. The newborn was positioned in the prone position and holding his head, the tube was inserted into the mouth, observing that there was no resistance to the path, noticing swallowing. In general, the newborn swallows the tube easily. If the tube is accidentally inserted into the trachea, it will not be inserted until the marking, as it will only reach the bifurcation of the trachea (causing resistance along the way). Therefore, if resistance is noticed when the tube is introduced into the mouth, the tube should be removed and inserted again (Peterson and Kutzler, 2011; Fuchs et al., 2024). After the tube is inserted, milk is administered slowly. The tube is removed right after the milk is administered. The tube must be cleaned after each feeding.

Figure 3
The newborn was fed through an orogastric tube.

Feeding was carried out with commercial breast milk substitute (Support Milk Dog®, Nutripharme, Brazil), at a temperature of 37°C, in the volume of 3 ml per 100 grams of weight every two hours. Water was provided between meals at a volume of 1.5mL per 100 grams of weight. The intervals between feedings were spaced over the weeks. In the second week of life, feeding was performed every three hours, and in the third week, it was performed every four hours, remaining as such until four months of age.

After 24 hours of hospitalization, the animal was discharged from the hospital. Owners were instructed about the animal's condition and how to carry out dietary management with orogastric tube at home, preventing milk aspiration, pneumonia and the neonatal triad. The newborn was separated from his mother and siblings and kept warm with blankets and thermal bags. After each feeding, stimulation for urination and defecation was performed, with gentle massage of the genitalia and anus, with the help of cotton wool moistened with warm water. To monitor neonatal development, daily weighing was requested via a digital scale with a scale in grams and assessment of the weight gain of the animal, since the newborn must gain at least 5 to 10% of its weight every day (Peterson e Kutzler, 2011). Upon return, 48 hours after beginning management with orogastric tube, weight gain, absence of sounds on lung auscultation, a normal respiratory pattern, normothermia (37.6°C), pink mucous membranes, and blood glucose levels of 98mg/dL were observed.

With respect to maternal information, the dog was primiparous, two years old, fed premium commercial food, vaccinated, dewormed, and had no history of illnesses during pregnancy. No drugs or supplements were administered to the mother during the gestational phase. The birth was eutocic, with the birth of six puppies. No changes were observed in the other neonates in the litter.

Periodic assessments were requested every seven days to monitor weight gain, changes in the amount of milk and changes in the size and number of tubes. In conjunction with food, supplementation with omega-3 fatty acids and probiotics was used every 24 hours.

Upon return, at 20 days of age, the owner reported the animal with nasal secretion and prostration after an episode of vomiting 30 minutes after feeding. On physical examination, the patient presented mild crepitus on lung auscultation, normal-colored mucous membranes, eupnea, a strong sucking reflex and normothermia. Additional tests, such as a blood count, revealed leukocytosis due to neutrophilia with a shift to the left: 39.9x10³/µL leukocytes (reference value: 6 - 17 x10³/µL), 30.3x10³/µL neutrophils (reference value: 3 - 11.5 x10³/µL); and a dorsal and latero-lateral chest radiograph demonstrating opacification with alveolar pattern in the right middle lobe, diagnosing aspiration pneumonia.

Antibiotic therapy with 22mg/kg subactram was administered intravenously every eight hours; 0.07mg/kg dexamethasone was administered intravenously every 24 hours; 30mg/kg acetylcysteine was administered intravenously every eight hours; and physiological solution (0.9% sodium chloride) was inhaled every eight hours. After 12 hours of hospitalization, the animal showed improvement in clinical signs. Upon return, 20 days after pneumonia treatment, a new blood count and a new chest radiograph were performed, results were within normal and reference standards for his age.

At 35 days of age, spontaneous closure of the cleft was observed in the anterior part of the hard palate, with the cleft remaining in the hard palate (posterior part) and soft palate (Fig. 4). At this age, weaning was started gradually, replacing the breast milk replacer with weaning pap for puppies (Papinha Desmame Premier®, PremierPet, Brazil) every four hours, and a number 20 urethral tube is used. Water was supplied between the feedings in a volume of 1.5 ml per 100 grams of weight. The animal had transparent nasal secretions, which made breathing a little difficult, and a child's nasal sucker was used as an aid. This secretion was possibly due to the passage of saliva into the oral cavity.

The puppy developed normally over the months, with an average weight gain of 13% per day, with good acceptance of the orogastric tube. At four months of age (Fig. 5), surgical planning to close the palate was carried out.

Figure 4
35-day-old puppy (on the left) and observation of the spontaneous closure of the cleft in the anterior part of the hard palate, with the cleft remaining in the hard palate (back part) and soft palate (on the right).

Figure 5
Four-month-old puppy.

Cleft palate surgery (palatorrhaphy) was performed in two stages. First, hard palate closure surgery (uranorrhaphy) was performed (Fig. 6). The following were used as pre-anesthetic medication: butorphanol 0.3mg/kg, intramuscularly; and acepromazine 0.02mg/kg, intramuscularly. For anesthetic induction and maintenance, the following were administered intravenously: ketamine 1mg/kg, lidocaine 2mg/kg, and propofol 2mg/kg. Trans-anesthetic analgesia was performed with greater palatine nerve block with 2mg/kg lidocaine.

To close the palate, was performed via the bipedicle flap sliding technique. Medial incisions were made parallel to the maxillary dental arches, with detachment of the mucoperiosteal layer of the palate, in the maxillary region, for a subsequent advancement flap, executed in the lateromedial direction along the entire extension of the mucosa. The bundles were united with simple sutures via polydioxanone synthetic absorbable monofilament thread numbers 5-0. Post-anesthetic medications were administered: dipyrone 25mg/kg, intravenously; dexamethasone 0.3mg/kg, intravenously; and tramadol 4mg/kg, subcutaneously. After surgery, the animal was discharged from hospital, with post-operative care: feeding through an esophageal tube for four weeks with weaning pap for puppies (Papinha Desmame Premier®, PremierPet, Brazil), every four hours. The following was prescribed: tramadol hydrochloride 2mg/kg, administered by esophageal tube, every eight hours, for five days; prednisolone suspension 0.5mg/kg, via esophageal tube, every 12 hours, for three days; dipyrone 25mg/kg, via esophageal tube, every eight hours, for five days; amoxicillin with potassium clavulanate 20mg/kg, via esophageal tube, every 12 hours, for seven days; and chlorhexidine 20% spray, topical use in the oral cavity, every eight hours, for 30 days.

Thirty days after surgery and with complete healing, soft palate closure surgery (staphylorrhaphy) was performed (Fig. 7). The anesthetic protocol used was the same as the hard palate closure surgery. The tissue was debrided and sutured in a continuous double layer using polydioxanone synthetic absorbable thread numbers 5-0. After surgery, the animal was discharged from hospital, with post-operative care: feeding through an orogastric tube for seven days with weaning pap for puppies (Papinha Desmame Premier®, PremierPet, Brazil), every four hours. The following was prescribed: tramadol hydrochloride 2mg/kg, administered by orogastric tube, every eight hours, for five days; prednisolone suspension 0.5mg/kg, via orogastric tube, every 12 hours, for three days; dipyrone 25mg/kg, via orogastric tube, every eight hours, for five days; amoxicillin with potassium clavulanate 20mg/kg, via orogastric tube, every 12 hours, for seven days; and chlorhexidine 20% spray, topical use in the oral cavity, every eight hours, for 30 days. After seven days, the animal took its first meal through the oral cavity, with no complications.

Figure 6
Before (left) and after (right) hard palate closure surgery.

Figure 7
Before (left) and after (right) soft palate closure surgery (arrows).

DISCUSSION

The incidence of congenital malformations in dogs is 6.7%, with a high mortality rate; approximately 68% of these newborns may die (Pereira et al., 2019). The occurrence of these congenital defects is attributed to prenatal factors related to genetic causes, which may be hereditary, or to maternal exposure to teratogenic agents during pregnancy, such as the administration of drugs, excess supplements, toxins, radiation, chemical agents, infectious diseases and mechanical influences (Casal, 2016; Pereira et al., 2019, 2022). It is known that cleft palate has a multifactorial nature, such as genetic factors, nutritional factors, or the administration of drugs to pregnant women, which leads to changes during embryogenesis (Apparício, 2015). In the case described, there was no maternal exposure to teratogenic agents during pregnancy. The highest incidence of malformations in dogs occurs in purebred puppies, accounting for approximately 84.4% of cases (Pereira et al., 2019), and cleft palate has already been described in Siberian Husky (Peralta et al., 2017). Therefore, the cause of the malformation in the puppy in this report is likely related to genetic factors related to breed.

To date, the type of inheritance of cleft palate confirmed in dogs is autosomal recessive. In other words, the malformation manifests itself only if the individual has two copies of the mutant allele, with characteristic patterns: the parents of an affected individual are generally heterozygous (Aa × Aa) and, therefore, phenotypically normal; although there is the possibility of an affected individual having one or both affected parents, such situations are unlikely (Moura and Pimpão, 2017). In this report, the puppy's parents did not have a cleft palate. However, the manifestation of this malformation tends to skip generations, as observed, for example, in grandparents (Moura and Pimpão, 2017), but the owners were unable to answer whether there were affected animals in the parents' family lineage.

The mortality rate from cleft palate is extremely high, reaching 90% of those affected, especially if there is no early assistance and management (Pereira et al., 2019). Thus, early diagnosis (by inspection of the oral cavity at birth) is essential to increase the chances of survival, and once the malformation is diagnosed, the newborn must be fed through orogastric tubes, avoiding false feeding and complications of this malformation (Apparício, 2015). In this case, the Siberian Husky puppy was diagnosed at three days of age and presented with the neonatal triad and aspiration pneumonia, with a risk of death. The triad possibly occurred due to the newborn's difficulty in breastfeeding the mother, since the cleft palate causes vacuum failure during sucking, culminating in inadequate milk intake, progressing to hypoglycemia, hypothermia, and dehydration (Pereira et al., 2022; Lourenço, 2023). It is essential that owners are instructed to check for the presence of cleft palate at the time of birth, seek veterinary assistance early, preventing neonatal mortality.

Orogastric tube is the method used to feed neonatal puppies with cleft palate because of its safety, practicality and good patient acceptance (Peterson and Kutzler, 2011). This management must be carried out until the animal is ready for palate closure surgery. Another option for patients with palatoschisis is nasogastric tube feeding (Gupta et al., 2023) but owing to the small size of newborn dogs' nostrils, a nasogastric tube is usually only possible after 30 days of age. However, in relation to the adverse effects of tubes, a study on human newborns revealed that both orogastric and nasogastric tubes did not cause clinical impairment of respiratory function; however, nasogastric tubes were associated with increased pulmonary resistance and episodes of bradycardia compared with orogastric tube (Gupta et al., 2023). In the case mentioned, management with an orogastric tube was feasible by the owners and was well accepted by the patient, with no adverse effects observed. Orogastric tube is the most recommended management for patients with cleft palate, reducing the risks of manifestation of the neonatal triad, aspiration pneumonia, and respiratory infections (Peterson and Kutzler 2011; Lourenço, 2023).

To use orogastric tube in the puppy in this case, the length of the tube inserted into the stomach was measured (preventing it from bending in the gastrointestinal tract), positioning the neonate in the lateral decubitus position and measuring the tube from the last rib to the tip of the nose. To assist with the correct length of tube insertion, a study demonstrated a formula based on the neonatal weight of dogs, where the Y stomach is the length of the tube to reach the stomach, and X is the weight of the newborn: Y stomach= 8 + 2.1 * X/100 (Furthner et al., 2021).

The surgical procedure is the definitive treatment, as it allows the animal to feed itself adequately, avoiding chronic nasal and lung infections (Apparício, 2015). In the aforementioned case, a surgical procedure was performed when the animal was four months old, avoiding reopening of the palate, which can occur early in surgery (Fiani et al., 2016). These reopening may occur due to the continued growth of the palate throughout the puppy's development. Furthermore, performing the surgical procedure at a later stage facilitates access to the palate and tissue by the surgeon (Hette and Rahal 2004; Fossum, 2021).

To correct the cleft of the hard palate, the bipedicle flap sliding technique or the overlapping ‘sandwich’ technique can be performed. The bipediculated flap sliding technique is widely used to correct this type of defect; however, it has the disadvantage of the repair being completely over the cleft (absence of direct support) (Fossum, 2021). This technique is performed on central cleft palates (Moura and Pimpão, 2017), which is the type of cleft presented by the patient in this report. Furthermore, it is an easy technique to perform and presents satisfactory results. The correction of the cleft of the soft palate can be performed by approximating and suturing the tissue, or if necessary, in animals with a lack of tissue or tension during closure, techniques can be used to overlap the nasal or nasopharyngeal mucosa flap (Hette and Rahal, 2004; Fossum, 2021). In the puppy in this report, tissue debridement and double-layer suturing were performed since the soft palate had sufficient tissue and did not experience tension during closure. The prognosis is good for animals with successful cleft palate repair (Fossum, 2021).

The risk of cleft palate manifestation in the descendants of an affected individual is 25%, and the normal siblings of an affected individual have an approximately 67% chance of being heterozygous (Moura and Pimpão, 2017). Therefore, as it is a malformation with genetic and hereditary factors, owners were advised to sterilize or not reproduce the mother, the affected puppy and littermates.

It is extremely important for veterinarians to know the best therapeutic approach for treating malformations, whether conservative or surgical, to provide adequate assistance, as well as to guide owners in the correct management of these defects, avoiding their complications. As preventive measures, care must be taken when choosing parents for reproduction, avoiding animals with a history of genetic defects, as well as maternal exposure to teratogenic factors during pregnancy (Pereira et al., 2022). Prenatal care is essential to prevent malformations and reduce mortality rates in newborns.

CONCLUSION

Management of cleft palate with orogastric tube feeding was effective, demonstrating adequate development of the puppy (constant weight gain), a reduced risk of neonatal triad and milk aspiration, good acceptance by the patient, the absence of adverse effects, and easy execution by tutors. However, it is essential to consult a veterinarian for immediate assistance in cases of complications. The waiting time for cleft palate surgery, performed at four months of age, proved to be essential to avoid reopening of the palate.

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Publication Dates

• Publication in this collection
  28 Apr 2025
• Date of issue
  May-Jun 2025

History

• Received
  02 Sept 2024
• Accepted
  26 Oct 2024