The Trouble with Trouble

By Betsey Lynch
(Reprinted with permission from Betsey Lynch. This article appeared in the CKCSC Bulletin, Nov.2005)

The story of one Cavalier's experience with SM and PSOM.
"MACH5, ADCH Mavourneen Out of the Blue"
Perhaps there is some truth to that admonishment to "be careful what you name them, it might come true". I have been asked dozens of times how I could name my tiny tricolor girl "Trouble". Her sweet expression and big eyes obviously fool a lot of people! Trouble is her name and trouble is her game.
My first indication that there might be something wrong with Trouble was when she developed a head tilt at about five weeks of age. Though it resolved itself within a few days, it made me uneasy enough about placing her in a pet home that I kept her for myself. The fact that she was beautiful and bouncy made that decision a lot easier. Trouble had a very normal puppyhood with no sign of problems until she reached ten months of age. At that point I began some agility training with her. We had already done lots of foundation work in the yard, but this was the first time she did any jumping or contact obstacles. I noticed when we went to train that she would start scratching the air near her neck when she became excited or tired while wearing a collar. Though syringomyelia (SM) was not the household word it is now among Cavalier fanciers, I knew it was "that scratching thing" that seemed to affect the breed from time to time. As long as I was careful not to overdo it or make her wear a collar for very long, she rarely showed signs of scratching, so I didn't give it a lot of thought. She began her competitive agility career two months later when she turned 12 months old and was an instant success. Within her first five months of competing she had qualified for the AKC Nationals and was the youngest dog in the entire entry of 520 to qualify and run at the Nationals in Houston that year (2002). Her first agility championship (MACH) was earned in May, 2003 at just over two years of age, making her the second youngest dog in history (all-breeds) to earn the title.
2003 was when information about SM in Cavaliers hit the forefront of the various breed email lists and publications. This, combined with increased scratching, made me decide to have an MRI done on Trouble in November, 2003. Since I live very close to The Ohio State University and its veterinary teaching hospital, this was relatively easy for me to do. I dropped her off at OSU on a Sunday afternoon and she was transported by the OSU neurologist to Children's Hospital for the MRI that evening. When I picked her up at about 10:00pm, the neurologist confirmed that she had a mild to moderate Chiari malformation and one very small syrinx. The neurologist did mention that it was surprising I had noticed these symptoms, considering how mild her case seemed to be. He did not advise surgery and said that she was free to continue her agility activities, though she may not perform up to the same level that she had in the past.
Trouble went onto new heights in agility in 2004, becoming the youngest dog (all-breeds) to earn the MACH2, MACH3, and MACH4 titles at the time she earned them. She also received awards from the AKC for being the top Cavalier in agility for 2003 and 2004, and she was the number 3 dog all-breeds in double Q's earned in 2004. She was still scratching a bit, and the duration of time she was able to tolerate a collar before scratching became shorter and shorter. She also did a lot of spinning and tail chasing, which may be unrelated, as her behavior has always been a little unconventional. Throughout this entire period, Trouble saw both an acupuncture vet and a human chiropractor (who has experience with Chiari patients) once a month each. She also saw a vet who practices Contact Reflex Analysis (CRA) every few months. These alternative therapies kept her feeling great and running well. Her supplements changed fairly often, but aspirin was an important drug for her comfort.
In late 2004, I contacted Dr. Carley Abramson at OSU in regards to a follow-up MRI to see if Trouble's SM had progressed. She advised me to wait until early 2005, as OSU would be starting a study on SM at that time and Trouble and her younger half-sister could be entered into the study. We went to see Dr. Abramson in February, 2005 for our pre-study evaluation and both girls, Trouble and Knaughty (I still hadn't learned my lesson on the name thing!), were scheduled for MRI's in March. It seemed like such a long wait but finally I dropped them off for their MRI's and an overnight stay at OSU. When I picked them up the next day, Dr. Philip March (the other neurologist on the SM study at OSU) came out and handed me an article to read before they talked to me about the girls. He said that this is what Trouble had. It was the article on Primary Secretory Otitis Media, or PSOM, outlining the results of a Swedish study on PSOM in Cavaliers. I had already read the article months before, but had not considered that Trouble might have it. This is what her discharge papers read: "MRI revealed a mild to moderate Chiari malformation with minimal to no syrinx formation (indistinguishable from the central canal). There was marked fluid to soft tissue densities in both middle ear cavities. When the MRI from 11/03 was reviewed, there was evidence of this otitis media at that date. " Knaughty was clear of SM and had small amounts of fluid in her middle ears.
Dr. March then referred us to the Dermatology Department at OSU where we met several weeks later with Dr. Andrew Hillier, the specialist that would handle Trouble's ear surgeries. For the procedure, Trouble would go under anesthesia for a CT Scan and if warranted, a myringotomy (incision in the eardrum) and an ear flush to eliminate the build up of mucus in her middle ear. Dr. March would also do a BAER test both before and after the surgery to see if there was a change in her hearing as a result of clearing out the mucus plug. The CT Scan showed that both ears were completely filled with fluid. The tympanic membrane (eardrum) on the left was severely swollen and required two incisions to remove the mucus plugs. The right ear did not show significant swelling and the mucus was removed from that ear with only one incision. Prior to the ear flush, the BAER test showed bilateral hearing loss. After the procedure, the BAER test showed a significant improvement in her hearing with the right ear improving more than the left ear. A culture of the material in the left ear was negative for bacteria.
Trouble recovered well from the surgery and was back to her normal self by the next day. An injection of pain killer due to the extensive work done on her left ear had kept her pretty drugged the night before. She competed in agility 10 days after her surgery and obviously felt much better and showed no signs of discomfort. We went back to OSU for a recheck three weeks later. The left ear was once again completely filled with fluid. The right ear had only a small volume of fluid. According to the Swedish study, it is not unusual for a dog to require repeated surgeries to clear up the condition entirely. The surgery was repeated on the left ear. Trouble bounced back immediately and competed brilliantly in agility only 3 days later. Our final recheck was nearly two months after that and both ears were completely clear and her hearing was nearly normal. The change in Trouble has been remarkable. She is hearing extremely well and has shown absolutely none of the scratching or neck guarding that she had before the first surgery. I can only conclude that it was the PSOM that had caused her symptoms and not her mild case of SM. The symptoms for the two conditions can be very similar and in Trouble's case, identical.
The further we progressed with Trouble's ear problems, the more curious I became in regards to its link to the deafness I've seen in my Cavaliers. Many of you may remember the article I wrote for the Fall, 1999 Bulletin titled "A Silent World". It documented the deafness I was experiencing in my dogs at relatively young ages. Since Trouble's ear surgeries made such a vast improvement in her hearing, it made me wonder if there was a connection. Dr. Hillier showed an interest in seeing some of my deaf dogs to see if they showed any signs of PSOM. Because of their age and heart status, CT Scans were not advisable, but he wanted to look in the ear canal and see if he could detect any bulging or other signs of PSOM. The first one he looked at was Trouble's mother. A BAER test showed that she had complete hearing loss in the right ear and advanced hearing loss in the left ear. There was a bulging of the tympanic membrane in her right ear - probably PSOM. The second one he evaluated was a 10 year old male that had been deaf for a number of years. He also showed a moderate swelling of the tympanic membrane and was probable for PSOM. Neither of these dogs showed any particular signs of ear problems, and never had any external ear infections.
OSU is writing a proposal for a study on PSOM. It is my hope that they will develop methods of diagnostics and resolution of PSOM that do not involve anesthesia.