Skin disease can be due to multiple causes

 

TOA PAYOH VETS toapayohvets.com Date:   18 February, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits The dog has itchy joints and genital areas  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   18 February, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129   On Sun, Feb 17, 2013 at 7:11 PM, @hotmail.com> wrote:   Hi Toa Payoh Vets, I am L.., the owner of my White Maltese Dog named P... I brought P... to your clinic about 2 months ago, when he had skin irritation/rashes. After shaving him bald and removing all carpets/clothes at home, I am glad that his skin rashes are now gone. However, he is suffering from some kind of "dry skin". I have attached some pictures. This redness/dry skin came back a month ago. The affected areas are mostly on his feet, joint of his forearms & genital area. I am not sure whether this is caused by him licking himself, causing such redness/dry skin or he licks himself because of the dry skin. I actually used the Elizabeth collar on him already, but he still manages to lick himself. In addition, I am currently only feeding him the Z/d prescription diet that you introduced. Hence, it should not be caused by food allergies. Also, I don't think it might be caused by external surroundings, as I only walk him out once a week (cause he is still suffering from the irritation). Please advise me further. Thanks!   PS: Thanks for solving the skin rashes problem. My family greatly appreciate your help! Best Regards, Name & Handphone given   EMAIL REPLY FROM DR SING DATED Feb 18, 2013 Thank you for your email and clear images of paw, joint and inguinal area showing inflammation of the skin. I am Dr Sing Kong Yuen. From your images, your dog has inflamed joints and genital area. It is possible that he is suffering from allergy to some substances in the environment e.g. contact with grass, dust mites, shampoos, floor cleaning chemicals, dog treats, food given by family members, dog perfumes and many other allergens. 1. There is a blood test for many allergens available for the dog. Pl let me know if you are interested. 2. Pl bring the dog for review of skin, blood test and an anti-allergic injection. 3. Pl contact me at 6253 3326 to discuss further as it is not possible to diagnose skin problems via email images in many skin disease cases. 4. Not all skin diseases can be cured with Z/D or equivalent prescription diet if there are more than one causes other than food. The cure depends on the cause or causes which are varied and sometimes hard to define. Updates will be at this webpage: http://www.asiahomes.com/petshotline/20130218joint_paw_genital_itchiness_toapayohvets.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: February 18, 2013 Toa Payoh Vets

 

Squamous cell carcinoma in a dog

1.  Hook
Video - 3rd day of surgery - going home. Dog looks forward to going home. 
What happened?



Be Kind To Pets info


2.  Introduction

Image of amputated dog.  Seen 2 vets. Vet 1 diagnosed cancer. Went to Vet 2 who X-rayed the lower leg skin tumour

Insert  X-Ray

and took skin biopsy to send to the lab for analysis. Lab confirmed squamous cell carcinoma of the skin.

Insert "Squamous cell carcinoma"

However Vet 2's operating theatre facilities not functional, so phoned me and surgery was done on Feb 15, 2013

3. Middle

Treatment - Amputation
- Chemotherapy not advised as it is not beneficial to the dog




4. Conclusion

4.1. What is the survival time? the owner asked.
Depends on: spread or not. If not spread, good chances of not recurring.

4.2  Nursing at home. Pain killers, antibiotics and confinement to a crate for 14 days
Video dog going home.






5. Tips & Advices

5.1  Small skin growths in the older dog especially should be removed by your vet early.
5.2  Small skin growths that do NOT heal at all may be cancerous.
5.3  Black pigmented skin growths may be squamous cell carcinomas. Cancerous. Best to get them removed when they are small. 


6. Be Kind To Pets & credits

1292. Toilet training an older poodle again

On Wed, Feb 13, 2013 at 1:20 PM, f@yahoo.com.sg> wrote:

Hi, I need your advice.

I have a toy poodle, she is spayed and can pee on tray 100%. But when she was 3 years old, I brought home a mini poodle puppy.

Since then she refuse to pee on the same tray. I put another tray in another room, she pee on the new tray some times. And rest of the times, she pee on the floor around the tray that the new dog pee.

I cant grab her to put her on the tray as she is very aggressive, and growl and bite.

I have tried to give her more attention, and also tried to beat her, but she just get worse

What should I do?

Thanks first

 

 

EMAIL REPLY FROM DR SING DATED FEB 17, 2013

 

Hi
Thank you for your email. It is not easy to give advice in your situation of two poodles competing for your attention. Have you tried "positive reinforcement" method of treats and praises for performance? Or the clicker method?

1. Spend time with the old poodle.
2. When she pees on the tray, give her treats and/or praises or bring her for exerciseThis depends which motivates her.
3. Use the old tray which has her urine smell. What happened to it?
4. Neutralise the urine smell on the floor.
5. Confine to small area again as in puppy toilet training.
6. Spay her if relevant.
7. Many weeks and months of positive reinforcement training may be needed to change the behaviour as the dog is an adult and not a puppy with ease of training.
8. Ensure she has no urinary tract infection - check with your vet. Urine test.
9. There may be a need to separate both poodles for some time and to wash your hands when you handle the younger poodle before handling the older one.
10. Pee trays may NEED to be washed frequently if your old poodle is a cleanliness freak and this may be one reason she will not pee on the pee pan but outside the perimeter..
11. Use the commercial pee pads to absorb the urine as a different approach and trial?

The above are some of my suggestions and I don't know whether they will work. Best wishes.

1291. The fat dwarf hamster loves the sand bowl

TOA PAYOH VETS toapayohvets.com Date:   17 February, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits The dwarf hamster has an itchy "eye bag"     Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   17 February, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 It is rare to get two similar cases in different species. The case of the dog with the left "eye bag" mirrors as recorded in: The snoring old dog had a big eye bag mirrors the case of the fat hamster who loves the sand bowl. She is one year old, female but weighed 68 g before surgery for a swollen lower eye area, much like an "eye bag" of the older person or the above-mentioned dog.Some 3 days ago, two sisters brought in this grey dwarf hamster. The elder sister dressed smartly like one of those models and so created a favourable first impression. "The younger sister is the one who loves her," said the mother today, Saturday 4 pm as she came to bring the hamster home. The younger sister came 2 days ago with the mother but since they did not know how to clear the eye of more yellow white particles of sand, the hamster was warded. I thought the mum how to do it today as the eye is still not fully opened. "Too much sand had gone into the eye," I said. "Your hamster sleeps in the sand bath like people going to the spa." "Sometimes she dozed off inside the sand bath," the mum laughed. "Sometimes she even pooped inside." The hamster had become a couch potato and now seldom went upstairs to a room. "She escaped through the opening in the upper hatch," the mum said. "We found her in the room. After that she would not go upstairs anymore." "This hamster could be too fat to go upstairs," I think. Yesterday, I saw her trying to go inside the cardboard roll which is the left over after the toilet papers had been used up. Her hind legs were caught outside the roll and she struggled. Fortunately I saw this incident. I snipped open the length of the roll so that she would not be trapped. ANAESTHESIA Zoletil 3 drops IM. Effective and sufficient sedation for lancing the lower eyelid abscess and draining the pus for a 68-g hamster. No need isoflurane gas top up and no fatality.  SURGERY I everted the lower eyelid at the medial canthus and incised with a scalpel. Pus oozed out. More pus from the upper eyelid too. More pus from further inside the lower eyelid to the lateral side. This was similar to the old dog mentioned above. Pus had formed deep inside the eyelids. Bacteria multiplied. The "eye bag formed." The hamster rubbed and rubbed. Redness and swelling. The owners agreed to hospitalisation for me to clear more debris and sand from the eye. The hamster went home 3 days later and the mother was taught how to restrain the hamster and put eye drops.  Updates will be at this webpage: http://www.asiahomes.com/petshotline/2013027hamster_eye_bag_toapayohvets.htm   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: February 17, 2013 Toa Payoh Vets

The old snoring dog has a large eye bag

 

TOA PAYOH VETS toapayohvets.com Date:   15 February, 2013     Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits The old snoring dog has one big eye bag.  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   15 February, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129 Around December 8, 2012, the owner consulted me for a 3rd opinion as the 15-year-old dog with a large left "eye bag" as seen in older people, was snoring the whole night long, disturbing the sleep of the working mother. This dog was most loved much more like a family member and so there was grave concerns when I said that anaesthesia was required as this condition was a surgical condition of pus collecting and forming inside the eyelids. "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   More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

Copyright © Asiahomes All rights reserved. Revised: February 15, 2013 Toa Payoh Vets

1289. Update: A hamburger tumour in a dog's mouth

TOA PAYOH VETS toapayohvets.com Date:   13 February, 2013   Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits Trust & Audit: A rare case of a hamburger tumour inside the mouth of an old dog  Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date:   13 February, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2013-0131 Blog 1286. Good dental hygiene is very important for people and dogs as some oral tumours form when the mouth is not clean. Yearly dental check ups will be ideal. In February 2013, I encountered a case of a dog with bleeding in the mouth and face. "Oro-nasal fistula also known as malar abscess or carnaissal abscess," I said to the two interns very confidently as this was a common problem in old dogs that seldom if ever was sent for dental check ups or scaling. I was 50% correct. There was a large oral tumour shaped like an oval elongated tumour! Veterinary medicine throws surprising oral tumours to me even after 40 years of practice! The dog was eating food under this tumour which expanded to fit the length and width and height of the oral cavity. The length of this tumour was estimated to be 10.5 cm long. I doubt I will ever see another case similar to this. Dr Daniel operated to remove this "hamburger" tumour using electro-surgery. I was present for a few seconds during surgery as this was his case and I had confidence he would be able to perform this surgery. "There was a lot of bleeding," he told me when I audited this case on Feb 12, 2013 (yesterday) and phoned the owner as well. He packed the back of the mouth with gauze swabs to prevent inhalation of blood into the lungs. Around 90% of the length of the tumour was excised electrically and then the remnants.  He electro-coagulated the bleeders in the remnants so that there would be no more bleeding.  Electro-cautery was effective in preventing bleeding.   The 50% calculated dosage of domitor and ketamine IV anaesthesia was just sufficient for surgery, with top up of isoflurane gas via the mask. This formula is now used by the vets for IV anaesthesia. It took some time to convince vets that this is a safe and effective formula as all vets have their own judgments and preferences of using various anaesthetics. Stocking a variety of anaesthetics is very costly as they expire and so I don't permit associate vets to order their favourite or their vet professors' choice. A veterinary surgery must be able to sustain its profitability and most associate vets don't bother with this aspect as they are not accountable for the bottom line.     Histology confirmed it is non-cancerous. It is known as a ossifying fibroma, originating from the soft palate according to the operating vet. There was also oro-nasal fistula which I diagnosed on first visual inspection and the rotten teeth black teeth as you can see from the image, were also extracted.  Blood test had not shown any abnormal findings and so this dog was fit for anaesthesia and survived without any problems.  In this case, the profuse bleeding from the excised tumour could be inhaled into the lungs and cause death by asphyxiation if electro-cautery had not been used to seal all bleeders successfully. From my phone call, the gentleman owner of this dog is most happy. As far as the dog owner is concerned, his old Chihuahua is OK and eating and that surgical outcome is what matters in the final analysis. "How long has this tumour exist?" I asked him. "I don't know as I don't look inside the mouth," he said. This is a very rare case of a "hamburger" oral tumour. Yearly dental check up of your dog over 3 years of age with your vet will prevent most oral tumours and rotten loose teeth. MY COMMENTS ON MANAGEMENT OF THIS CASE: 1.  Electro-surgery was the correct choice. 2.  IV anaesthesia with top up IV would be the choice in this case as isoflurane gas use by mask was not practical. However, the IV anaesthesia at 50% had lasted a sufficient amount of time to complete 90% of the surgery and isoflurane gas top up was effective in this case. IV anaesthesia top up, the drugs would be injected with the IV drip or the syringe with the drugs would be attached to the IV catheter.   This webpage: http://www.bekindtopets.com/dogs/20130214ossifying_fibroma_oral_dog_toapayohvets.htm Toa Payoh Vets Clinical Research

Copyright © Asiahomes
All rights reserved. Revised: February 13, 2013
Toa Payoh Vets

1288. Follow up oro-nasal fistula 6 years later

TOA PAYOH VETS toapayohvets.com Date: 13 February, 2013 Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits A Facial Wound does not heal: Oro-nasal fistula follow up 6 years later Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Case written: November 15, 2007 Update: 13 February, 2013 toapayohvets.com Be Kind To Pets Veterinary Education Project 2013-0131 "Why didn't you come for the surgery?" I admonished the lady owner of the Pomeranian. "You wasted more money buying more antibiotic powder from the pet shop to dust onto the facial wound, hoping it would heal. "For ordinary skin wounds, the antibiotic powder would heal them, but I had already explained to you why the wound would never heal without dental extraction of the infected tooth." Her 4-year-old Pomeranian had a weeping wound of around 0.5 cm in diameter below the left eye, above the maxillary 4th premolar tooth. It did not heal over the past weeks despite various medications and powders she had sprinkled on. Some 14 days ago, I had patiently explained to her by illustration how the infection from the root of the maxillary 4th premolar spread into the nose from the diseased gums to the skin below the eye. The bacteria from the decayed roots of this premolar had dissolved the nasal bone area and made a hole. This condition is called an oro-nasal fistula. Dental surgery to remove the infected premolar would resolve her Pomeranian's non-healing wound problem once and for all. "The vet did a slick sales presentation to make me spend money unnecessarily" the husband of the dog owner must have told her. "How can a rotten tooth inside the mouth cause a hole on the skin below the left eye. This doctor is nuts and is desperate to make money. Mouth and nose. So far apart. How can there be a connection?" Back to the present, I said, "Surgery was to be done 7 days ago after 7 days of antibiotics. But you did not turn up till today --- 14 days later!" The middle-aged lady shook her head. I forgot my bedside manners by scolding her. The customer is king. The general anaesthesia and tooth surgery was affordable for her as I had discounted my fees but that money could buy another sari from Niven Road's sari shop. I was annoyed because there was an optimal time to do extraction of the infected and decayed tooth. It was after 7 days of antibiotics and she had not kept her appointment nor cancelled it. She just did not turn up as there was less weeping of the wound due to antibiotics. However after the course of antibiotics, the bacteria in the infected teeth had resumed their attack and the facial wound became wet again. The lady pulled up her fine and most colourful sari and smiled sheepishly, "My husband wanted to use the money for the dog's anaesthesia and surgery to go to India for holiday lah!" Now that the dog is no longer on antibiotics, should I operate? There was no urgency in the sense that it was an emergency. But it would be in the best interest of this poor dog to be cured as soon as possible. The Pomeranian's teeth were not brushed at all as this is a common practice in Singapore. Initially bacteria attacking the food debris on the tooth gum line would die in 3-5 days to form a plaque on the tooth surface. As the dog's teeth were not brushed daily or at all, more plaque accumulated on the surface of the teeth. Soon they become tartar (calculus). The gum became infected, leading to gingivitis. The root of the 4th premolar tooth of the upper jaw became abscessed due to bacterial attack. Abscess tracked upwards towards the nose and side of the face. Soon a facial wound appears to form a connection (oro-nasal fistula) between the tooth and the skin, discharging pus daily. As the pus and fluid from the mouth is discharged daily, the wound can never heal as it is always infected. The decayed 4th premolar and lst molar became loose as their roots had been exposed as the diseased gum diseased shrivelled. The supporting structure of the teeth was weakened by the bacterial attack, leading to a loose tooth that would fall out in time to come. At this time, there was no choice but to extract these two loose teeth. Otherwise the Pomeranian would suffer from daily toothache as the owner's husband might thwart her from doing the right thing for her dog. I put the Pomeranian under general anaesthesia gas and got the offending teeth extracted and scaled the other good teeth to remove the tartar. "How can a rotten tooth inside the mouth cause a hole on the skin below the left eye? So far away. This doctor is nuts and is desperate to make money." the husband must have had advised his wife. "The money is better spent travelling." So, at first, she did not heed my advice to do extract the infected premolar No. 4. The facial wound just would not heal and it cost her time and money to apply medication with no good outcome The facial wound closed after a few days when I phoned the lady owner to follow up after extraction of the infected teeth. "You are a good vet," the lady surprised me with her compliment especially after my admonishment. She needed not clean the wound daily and her dog was more active and has a livelier demeanour. And what more joy could a lady have than to see her companion having a higher quality of life? BLOOD TEST & OTHER PROCEDURES. There was no pre-anaesthetic blood tests to assess the liver and kidney functions and blood cells of this younger Pomeranian. Veterinary costs would be additional $150. Most likely the poor Pomeranian would not receive any veterinary attention if an increase of $150 was added to the veterinary expenses. Therefore I did not require blood tests and had reduced costs in not prescribing pain-killers and pre-op i/v drip and antibiotics. Physical examination of the Pomeranian indicated that there was no cardiac problem and there should be no death from general anaesthesia. The dog's anaesthesia was uneventful. He went home on the same day and had no more facial wound below the eye as the cause was removed. UPDATE IN FEB 2013 I have not seen the Pomeranian since 2007. He was 4 years old then. In Feb 2013, the owners came with the Pomeranian wanting to board the dog for Chinese New Year. I took the following image of him with a face that has no more oro-nasal fistulas for the benefit of readers. This webpage: http://www.bekindtopets.com/dogs/20080825Pomeranian_Oronasal_Fistula_Singapore_ToaPayohVets.htm More interesting cases of dental problems in Singapore dogs: Toa Payoh Vets Clinical Research: Mouth problems in Singapore's dogs Toa Payoh Vets Clinical Research