Lovely. Thank you very much for, listening to this. We can talk about imaging rabbit heads, today.
So, why? What's the aims, really? Well, first of all, actually, I really like imaging, so we do a lot of it and, got, to find out quite a lot.
And there's also a lot of things that go on in rabbit heads. So we deal with them a lot of the time, not just dental disease, but a range of different diseases. And imaging is really, really useful for diagnosis, for prognosis, and generally planning what to do next.
And there's a lot of different ways of imaging, there's a lot of different modalities, and that means you can cover a lot more different conditions by using different ones in different situations or even simply, just doing lots of different ones for, for, for whatever. So what I'm trying to do today is show you what you can do in practise, . Doesn't have to be a specialist practise or anything like that to just what you can do with what you've got.
And also show you what you haven't got is what's possible and when it's useful to use it in whatever circumstance. So some of those ones are quite expensive toys, so we can talk about endoscopy, we can talk about CT. And the idea is really to show what they can do.
And that might lead to think, well, is it worth getting them? Or is it worth referring for them? And that might be a full referral to investigation stuff, knowing that glass ceiling, or it might be just simply for outpatient imaging, getting the images back, and then interpreting and doing whatever.
And for some of these too, I'm going to delve into some of the financial aspects as well. So again, if you're thinking about is it worth getting endoscopes, the answer, by the way is yes, definitely. But if you're thinking about it, then we're gonna look at some of the financial aspects of of how you can do that, to start off, to advance, and to and to make these affordable, toys in practise.
Because I have a conflict of interest, am I selling referral service? Well, I don't know to practise anymore, so, . It doesn't, doesn't affect my income if you refer or not, but much I like taking pictures and actually I'm going to be out of full-time practise fairly soon.
So no, I don't have a conflict of interest at the moment. I just really want to share what I've learned over the few years and just show what I think is the most valuable stuff to do with rabbit heads. So we're gonna look at within these areas, the technical and logistical aspects of taking images, we're gonna look at the indications for them, look at some results we get from those, and you're gonna see a lot of pictures, which is a great thing about imaging because you get pictures and I like visual stuff.
So you're gonna start with radiography, and this is very much our standard tool in practise, you know, we've all got radiography. We can do this with plate, but digital is better if you can blow things up, we can move them around a bit more. But we've got radiographs, or cope of radiography, and that's really useful.
In the skull, we're gonna do this all the time for dental problems, upper respiratory problems. We're gonna look, use it to look at nasolarymal ducts, because we can stick contrast in those. We might be able to use it for temporomandibular joints, and we do get issues with those sometimes in rabbits, but, .
This is not the, the big, big, big thing with this, but we can do it a bit, and we can do a bit with the ears as well. And again, we're gonna move on to what else we can do with the ears, but we can get some information about ears from radiographs. So dental disease, it's really common.
We've seen rabbits with dental disease, and it's probably one of the most common indication we have there too. And radiography is a standard tool. In fact, it's fair to say that.
You can't really adequately or completely assess rabbits for dental disease without doing radiography to look at the dental routes. And that's where you get, you get information about the state of the roots, and that gives you a prognosis, which is really important, often as much as diagnosis, which you've often got from the clinical examination and oral examination as well. So this is indicating all dental cases.
And certainly anyone I do for the first time, I will always radiograph as well. I will probably not radiograph every single dental because it is more costly, but certainly if things are changing, then I will re-adiograph and see what has changed within the roots. So we'd also say you're saying that a bit further, where there's dental pain suspected I've radiograph.
So that might be if you ain't doing right cases. The rabbit who just isn't right, isn't eating well, losing weight, just generally a poorly rabbit, worth X-raying the skull, see what the dental roots look like. Recurrent gut stasis cases too, because a lot of these relate to chronic inflammatory conditions to chronic pain, and dental root disease is a big, big feature of that.
So radiography is, is. One of those things you do every single day. What I'm going to do is the grading system for moories, or what I use anyway, which is slightly different.
Everybody's got a different grading system, but this is how I do it and how I look at the teeth and assess. So for normals, start with the I do two views basically. I do a lateral view, laterolateral, and I do a dorsal ventral.
This is a dorsoventral view obviously. What can we say? Well, The big thing is you've got to get these symmetrical.
It's quite hard to do some cases, but you want it symmetrical because you can really adequately assess. So we start looking at the bully, mid layer bully, and you want to see them symmetrical as possible, at least even in size and position. We want to look at the midline here, we can see it quite clearly.
It needs to be as straight as possible. And the other big key indicator is the first cheek tooth, upper cheek tooth on each side, and you want to see a nice halo around it seems outlined well. And that, that's, that's pretty much what you're looking to see.
You don't wanna see too much root extension into the into the surrounding bone, and you don't want to see too much thickening of the mandible which is running along here. And this is fairly, fairly normal dorsoventral view. In fairness, for teeth, I find it less useful for my lateral views, and that's why I base most of my stuff on.
And here is again a relatively normal lateral view. It is very hard finding a true normal for dental disease, and this one is not quite normal, but it's as close as I could get. Now within this.
We can, we're obviously gonna look at look at the the the the shape of a teeth, how we, how we link together. One big indicator is you want to see a little zigzag between the murders, he's not quite perfect here, but the murder should zigzag interlocking with each other. The incisors should not meet.
Should be a little gap we lower inside just behind the upper and it should be chisel shaped and it's not quite meet. So if motor's meeting, the insiders shouldn't. In real life, what they do is slightly slide the jaw so that they will chew it sorry, prehending food, they'll pick up with the insiders meeting and the molars will no longer be opposed in the same way.
Now then we start putting some lines on. There was an awful lot of information about lines and dental disease. And if you want to have a look into it, it's a lot of, publications, showing these.
There's a lot of controversy about how well, how, how much, how useful they are, and what they show, and whether they are misleading at times. But have a read through, as say, different people have different schemes. But this is the very basic ones I use, and I don't use a full line system by any stretch of imagination.
So draw lines along the hard palette. I'm slightly exaggerated here but along the bottom jaw, and the idea is they should meet somewhere down to the bottom left as I'm looking at the screen now. They should not be parallel and they should certainly not diverge.
They should converge just a long way down to the bottom left here, and that's normal. I'll also put a line across the top of the molars. This should be relatively there should be in a nice block.
Here we've got so you can see abnormality got a little bit of motor root protruding beyond here, but they should be roughly in a straight line here. And then try to do something similar with the lower insight lower molars and again, less block like than the upper, but again, there shouldn't be too much protrusion and and if you like splaying beyond that nice square block. And the final place to look at is in that first lower cheek tooth.
And we want to see that as fairly straight. This is pretty good here. We don't want to see a too big a curve.
So those are the big areas I'll look at when I'm looking at at the molar roots. So I don't tend to do oblique views. I actually find these quite hard to interpret.
I might do one if I'm looking, say, specifically an arcade for say for abscessation or something, but I very rarely do them as standard. So let's start with our grading. We start with grade 0 should be perfect.
Grade 1 is our our sort of if you like our most mild form of dental disease. We're looking at, well, we're still looking here at these lines should converge, so we're down to the bottom right in sizes they have a gap here. They're not opposed and we've got this here we've got a lovely zigzag here.
This is really this is, this is better than the previous one. We have got a little bit of playing. Of the lower molar, so we can see that that caudal molar is, is, is not in the block at all.
And again we've got some more exaggerated protrusion of the upper molars. And this is very, very mild dental disease. Progression goes on to grade 2.
It's a difficult one to work out this one. And again we've got further displaying of the lower molars here. We've got.
Further taller upper molar roots here. And we can see that although these will converge, they're going to converge a lot further down to the bottom right, and we're beginning to get a little bit of interaction between the incisors. You can see it better on this picture here where we're going to lose a chisel shape as well.
Again, convergence, but a lot a lot more parallel than they should be, and again looking at the displaying of a roots. Here and here. The zigzag line, by the way, is beginning to be lost here and on here we can see it's lost completely.
So that progresses to grade 3, and again we can see now we're getting more parallel. Palettes again we can see that here, these are more parallel, they're probably not like to meet for a very long time. We're getting much more splaying and potentially some reaction around these, .
Lower molar roots and just beginning to get impaction onto the bottom mandible here. And here Again, the incisors now are meeting. Over time they're also looking a lot squarer.
You see we're not, not, it's a chisel here, lots of chisel there and these upper upper ones are definitely using that too, and you can see how they're meeting almost end on end. And this is progression to to grade 3. Grade 4 Further progression we're getting impaction of the mandibular molar roots onto the cortex of the mandible displaying the teeth here, again we're going to get some reaction up around these upper molar roots and these palate and the .
And the mandible, they're being definitely parallel now, potentially even just beginning to diverge. And again, the meeting of the incisor is imperfect and progressing. I'm beginning to get a little bit of impaction of the incisor root onto the palate here and reaction on the lower incisor route there.
And finally, we end up at grade 5 where basically we have a complete disaster on our hands, where it's a nice square, . Incisors, we have full impaction of the incisor onto the palate. We have teeth all over the place here.
We, we'll end up with loss to. We're going to get breaking through of molar roots through the mandibular cortex, and bone density loss. We're getting destruction of roots here and also big reactions up in the up up in the in the upper jaw, and this is really beginning to look now that we can get starting abscessation fairly soon.
So we can see our stages there from from grade 1 to grade 5, and we can do that and we can give that helps give us a enable us to follow the the cases through and see if how the disease is progressing. It can also give us some idea of prognosis to the clients, which is really important. It might give us some indication of how fast the disease can progress or even whether we're using diet and stuff, we can slow that down.
In terms of, abscess, surgery planning, again, we can use radiography for that. When we do start getting these abscess produced. First of all, I think get prognosis.
So here we've got a case where we've got a nice discreet abscess here. We can see it's involving, cadal molars in the, lower mandible, and we can, we can take these teeth here out, and we should be able to get good resolution, especially mystized at the same time. On this side here, we can see you've got destruction, we've got infection likely in probably all the arcades, the incisors are destroyed as well.
These are cases where surgery is unlikely to make much difference and personally I tend not to progress to surgery in those ones, but for more palliative care. And that's, that's really helpful again. Is surgery indicated?
Is the prognosis good or bad or indifferent, or downright poor? And so we can really And so what we want to do. If we are going to operate, we can start identifying the teeth are involved with the abscess and which ones need to come away and and be removed.
I tend to use Radiography a lot too in cases where we've got incisor overgrowth. It may seem fairly obvious, you know, we, we do have case and the older animals tend to be secondary to the, to molar disease, and that's obviously a good indication for radiography, but the younger animals, when it may be linked to trauma or it may be linked to, congenital problems, why do we still need to radiograph? Well, again, there may yet be concurrents.
I have seen murders in very young rabbits occasionally, especially we've got congenital issues. I think it's interesting though if we had some trauma. What else is going on there.
This is not an overgrowth, but we have got something interesting which I've never seen before, which is, and this is an infected pig tooth, and we can see the big reaction around the base of that pig tooth. So it's worth finding bit more issues going on there too. Meaning older animals too, we can see have we got incisor root disease, have we got infections, what have you around there?
Have we got silus involvement from that, which we'll talk about later. So is removal indicated? Is it, going to be helpful?
What's it going to actually achieve if we do so? Those sort of things we might see, . This is quite an early stage again we get the incisor upper incisor in behind the lower, and in this case it's probably largely down to we've got quite tall molars here and we can see the divergence of that of those palate and the mandible.
So this is the jaws are forced apart and beginning to get this overgrowth or or male positioning of the incisors. The other thing that helps us to do sometimes is this is obviously one where we've operated before, we've removed the upper upper incisors. We've got a regrowth of a lower incisor.
But if you have a look here, we can see you've got a little microfracture in that incisor too. So much I'd very much like to remove that tooth. I probably won't in this case, or not for a while, because what I do know is if I start to remove that, it's going to break and I'm going to have to go and operate again anyway because that's going to be left behind.
So what I would do in this case, I'd trim the incisor off, I would allow it to grow, let this piece fall away naturally and allow the more root to come through. So we're probably gonna delay the surgery for a few months at that rate. So it's really useful some of that planning.
So we also use radiography for upper respiratory disease. This enable us to visualise things like sinuses. Sometimes we do get nasal abscesses, and we can see those, and it lets us identify the role of the molar or the incisor roots within that because both of them can be involved with sinus disease.
Indico signs to go ahead and look at this. Obviously got nasal discharge, sneezing, wet eyes as well, and, and, and wet eyes can, can go along with dental disease, pure and simple, but also wet eyes, especially if you've got any paraent in there, can be linked into upper respiratory as well. And frankly, I think this is better than a swab.
Swabbing in the nose is very rarely actually gets into the correct place. And so you often get pick up of commensal bacteria, like Paula, for example. And, Again, we've often got encapsulated lesions, got chronic lesions, so it's great identifying bacteria, but you know, if they're not from the right place and there's a big capsule around the actual lesion, it's very unlikely antibiotics which penetrate in there anyway.
So it doesn't tell us that much. So personally I don't, I swap very, very few of these. If I am sampling, I'll use my imaging to direct where I can pop a needle or I can pop something more physical to actually get out a sample to send the culture.
And this sort of thing might see, I think we can work out from our previous thing. This is a pretty advanced grade. See penetration of antibular molar route there.
So here we're looking here at grade 5 dental disease. So is it a surprise we've got upper respiratory problems as well? No, it's not.
We can see reaction around his incisor, and here is the axillary sign as we can see outlined nicely here. And this may be related to the incisor route, but probably with a little bit of gap there, probably not. This is probably more related into the reaction infection around this first, cheek tooth there.
So we can see that too. In this case, again, another advanced grade, dental disease. So many other issues you may want to consider, but why has it got discharge again, we can see Max side is beautifully outlined.
Along here, it's probably this is the ventral assessor and axillary side we'll build a bit more later on too. And in this case, probably more directly related to the incisor route itself. Now, if we didn't have all this stuff going on in the molars, this is a case where just sometimes you might remove the incisors to achieve better drainage.
In reality, it tends not to work quite so well that way. It's tempting, but often you'll cause more reaction, but just occasionally it's the right thing to do. Stemming from that, we have the nasallacrimal ducts.
And One thing I did mention here too, one thing you can do with these is you can pop a needle into here. You can take samples and you can flush, and the radiography does enable to direct exactly where you want to put that. So moving on to nasal la conducts, these are closely associated with the molars, they're closer to incisors, and they're very closely associated with that sinus, which where they run.
And in these cases, these these rabbits with very pussy eyes, lots of very white discharge, especially when you press just below the eye and you get pus coming up from the nasal act or duct openings, . This is really, you know, what we want to investigate and see why they're blocked, why they're maybe stenosed, why there's an issue there too. And we get, we often see dry material over the face, maybe see a facial dermatitis as well.
It's really irritant this, and, it's incredible how even someone just cleaning and clipping up the face will, just make the rabbit feel better and actually calm everything down a lot more than that she's doing a lot of things too. But sometimes these are persistent and you want to know what's going on there, what else do you need to do. And so very easily we add 0.5 mil to 1 mL of contrast, typically, when we highly iodinated, a positive contrast, and we just pop in there via via cannula, has a nice benefit effect of flushing through some of the material and give a little bit symptomatic relief, but we soon take pictures.
Now, we'll talk about CT with this later on. With radiography, the problem we have is overlay. So you do have to do one eye at a time.
And I would, so I got bilateral cases, I would tend to do them on different occasions, because it's very, very hard to, to read the second side once you've done the first side. What you can do if you had to do it in one go is put contrast in and then flush through with saline, just to get, get the con much contra out of the first side as possible before you put contrast in the second side. So here we go.
We have a case here, slightly bleaky view, but we're looking at, this area here. Here's our side we can see some reaction here to see a bit of a halo around here. What's, what exactly is going on with that too.
We can add a contrast in and we have a massive dilation of ducts, and now we can see outlining here of of a lesion within that sinus. That's where we get a sample, potentially even it's worth opening up the sinus to clear that out. But we've got to dilation of duct and that that can be really helpful.
I see, we see more subtle stuff too, but it's worth doing. Temporal mandibular joints really hard to visualise on standard uses, so I would tend to use a rostrachordal open mouth as much as possible view. Rise to where it spots the real cheat in this slide in this picture here.
But at least we can see here we've got a nice view of a fairly normal joint here and on this side we have some arthritic change into there. Now you can then direct a needle into into their own sample. But, or you can actually even put drugs in there occasionally too.
It's fiddly, but you can do it, and that can be useful. And we'll go on to ultrasound in a moment, but you can ultrasound guide into into it as well. You can visualise an ultrasound if, if you, if you're careful, .
The important we're looking for is a cause of anorexia in rabbits and typical dental signs. Often you'll see the slanted in sizes just like in in in in the dental case. What you will notice when you try and palpate the mandible and move it around, you know, there's a lot of pain on that side of the rabbit really resents it, but you do need that roster record.
It's fiddly, and positioning can be awkward, but it's certainly possible, and, with, with the tape and patients. And we we get nice views. Do you get quite nice views too with the, the dental roots along the mandible in particular.
And we'll talk about the bully in a moment as well because we do see a good view of the mid lay bully, in this position. Otherwise, for head tilt cases, general ear suspicious cases, which might be getting more non-specific pain, or recurring gut stasis type cases, then we will, tend to, do standard dorsoventral use where I find it really comes into its own. And what we're looking for is congestion and maybe for osteomyelitis, very old fuzzy slide taken I'm afraid from an old plate.
But again, we can see the fuzzy osteomyelitis on this side. Bear in mind these are very rarely solely unilateral. We've got season one year you're probably gonna have the other two, but I think there's no prize for guessing, that, this area is very congested indeed.
We will see the rabbit is actually even on this, it's tilting to the, tilting to the affected side. And this is important. It's very hard positioning head tilt cases, which does make for more subtle lesions, difficulty interpretation.
But they're tilting for a reason, especially with chronic ones as well, because, you know, the muscles are set, it's really quite hard to, hard to move them and get them right, so that can make positioning a little bit more difficult. In terms of sensitivity, it's not very sensitive. This is the big problem, and you've got to have major change to really see it, see it on X-ray.
The other difficulty too is I very much want to use this to decide whether the bullet is intact. So in this case I'll be doing ear flushings to clean out discharge, maybe to sample, and what I don't want to do is if I've got a ruptured bullet. Then I don't want to be putting, a lot of saline into there because I'll create myself a proper abscess, by, by moving material into surrounding tissues.
For that reason, Roster record is better to go back to this, we can actually get some good indication of the bullet integrity from there. But X-ray can do a lot, and actually we can pick up some, some more subtly signs too. And the thing which is worth looking out for is a relatively normal bullet.
We've got some congestion there too, a little bit of thickening of bone in places. We've got a nice view here too, but if you look on the other side, this picture is courtesy of Aidan Raftery, is we've got remodelling. And certainly when you look at this fissure here, if you've got positioning of the bullet rostral to this, then we've almost certainly got remodelling of, of the buller, and that's an indication we have got some degree of disease, even though at first glance these don't look, particularly, diseased.
So, again, that we do need excellent positioning to really, really get this correct. And again back to our roster record of you, what can we see with this, . We can see a thickening of the bullet here, the media bull here and here, and we can see we haven't got air in here.
We've actually got material in there. So although not particularly sensitive, it is giving us more information than we will get necessarily from a dorsoventral view. Now what we can do to augment that is we can use ultrasound.
And wherever we're suspecting fluids or soft tissue changes, ultrasound is really useful, and we can use that in the skull as well. I mentioned using it for the temporomandibular joints. We're actually trying to get a needle into there, but we can also use for eyes and ears here as well.
And for ears it is an add on to a radiography. So we have got some congestion and we're not sure. Then what we can do is we can actually just clip up just ventral to the ear.
We can pop a probe onto there and we get a view of fluid, and it will give us some better sense of bullet integrity as well, again, not perfect, but not bad at all. And it's very useful in case of ear-based swelling because we've got a lot of material we can, if you like, use as a window to visualise strength. This is the type of thing you get, so here is the ear canal here we can actually see the coruminous material within the canal, and that allows to see down, we can see the part of the buller wall here and we can see material extending into the the the the the ear bulla.
So that's quite useful, and again, adding, adding them both together. Where I love ultrasound in the head is for doing eyes, and it really helps that, rabbit eyes are pretty bulgy, and that helps, so we can get, get probes to them quite easily. They're very big as well.
And they're also really insensitive. And that's fantastic. And it's very rare to find a rabbit who won't tolerate this, conscious.
So if in doubt, put some proximettacaine on the eyes first of all, to make them even less sensitive, and then put just a big blob of ultrasound gel on top of the eye and that's a stand off there. We don't be pressing too hard on the eye, so just, just do that. And when's it indicated, well, asymmetric eyes for sure.
So if you've got . You know, one eye sticking out. If you've got a really bulgy eye like here, that's a really good, good indication for doing an ultrasound.
And if your eye's opaque, and we will see different reasons for eyes being opaque, that include abscesses, and tumours as well. So it's really useful if you can't see through it, stick an ultrasound onto it, and that'll give you a lot more information about what's going on inside. And I find it's really useful.
And what we can do is we can be visualise various bits and pieces. So inside the eye, we can have a look at the lens, we look for tumours, we can look for abscesses and stuff like that too. But we can also look at retrobar structures because we've got a nice fluid filled body here, we can use it as a window, we can look behind.
And this is a really good way of diagnosing retroulbar abscesses, which certainly on radiography is really hard to do. And this is what we sort of thing we'll see. We'll see we've got eyes got anterior chamber, you can see a posterior chamber, and here we can see a cavitating lesion, retrobulba, and if you're really lucky some days you actually see the tooth in it too.
Here we're measuring as well. We can do that. So again, we can, we can even use this for monitoring and assessment.
More pictures of retrovisis again, we can start seeing the lesion here. We can see the cavity in the middle. Sometimes you get very solid structure here, and that can just be immune gland hypertrophy, but normally it's going to be retrobar abs.
And again here we can start seeing major cavities falling through here, a nice big lesion, so yeah, we can see this quite, quite clearly. Within the eye again, we can see different different things. We've had a few cases in the last year of lens flexations and again we're presented as a bulging eye.
Typically, we'll look at those, we do tonometry first of all, and then move on to ultrasound. And very opaque too. It's very hard, hard visualising a lot too.
And here we go, this is an anterior displace lens. We can see how the anterior chamber is really reduced, and we can see the lenses in a very weird position here. And this was a posterior, like sated lens, and again anterior chamber, we can see the iris here, and here's our lens, which has been back in in the posterior chamber for a long time, lost its blood supply and become calcified.
Now in both these cases, we're actually able to control the pain and the inflammation with with with topical anti-inflammatory, which was great, but again, indications potentially for going in for nucleation in these cases. So really useful to do get yourself a diagnosis and very simple, again with the equipment you're generally gonna have. So you can move on now to things which you may not have, but, I think it's, personally, I think this is the thing if you haven't got it, you really do need.
Gonna talk about endoscopy. So you can talk about rigid endoscopy. We can discuss some expenses involved with that in a moment.
And I use this for ears, for noses, for dental examination, and also looking at the back of the, back of back of the throat, and actually, of course, for intubation as well, and that's really important. Intubating rabbits is not easy. Using blind techniques can lead to trauma, especially on my larynx, and you can reduce that very much by using an endoscope.
So what gear do we use for a standard is a 2.7 millimetre 30 degree scape. With that, I'll typically have a working sheath.
And some biopsy grabs. Now that's gonna do you most things. That'll do your throats, that'll do your ears, that'll do, intubation.
It's gonna do noses in big rabbits, won't do in small rabbits. It's, you're not gonna get very far in. We certainly have a look just inside the areas, but that's about it.
In the small rabbits, you'll probably need a, a 1.9 millimetre, scope, to, to, to go much further. But to start with, this is a really good workhorse scope to use.
Very nice to get a video and screen with it. The, obviously video allows you to record, but it also gives you magnification, it allows you involves you know to work at a more sensible height and position, . But actually you don't need it, so if you wanna save money to begin with, look down the scape, do what the the old fashioned way and just actually look down that scape, for, you know, just through through it, you, they're just I say disadvantages, but actually it's perfectly workable doing that.
What you do need is a good light source, and the nice thing is you can get little handheld cold light sources which are they're under 100 pounds and they give light the battery operated very nearly as good as as from a proper cold light source in a unit and at much lower price. Disadvantage you have to keep those batteries charged. So this is the extra thing to get if you want to, 1.90 degree scope again can come with sheath and grabs as well for smaller rabbits.
And, you know, if you're feeling really smart, get yourself out to endoscope, and those are great, . Not only because they're sort of flash, I mean the chief is built into them, they're really robust, so for oral examinations, and contra it's that can be quite can be quite, quite useful. Of course, they do cost a lot of money.
They, if you get a full kit and set up, it's gonna cost you several 1000. But you can get secondhand, equipment quite easily from both medical secondhand stores and also online. EBay is actually a really good source for endoscopes, not quite as good as it used to be, but it's still there.
Other sites do exist. You can get cheaper brands. We all think about the top brands like Storts and stuff, but actually there are cheaper brands available, and that's not a bad place to start from.
And you can also get these much cheaper Bluetooth scapes, and again starting off, they're all right. They they they they work fine and again have the advantage of getting yourself onto a screen, get magnification, and again, very nice for showing clients what's going on too. And actually all together with a, you know, handheld cold light source, cheaper for Scope, then you can get a cost of well under 1000 pounds.
Are those cheap ones as good? No, they're not. If you look at end on end, you'll see the the smartscapes have got much more glass in them.
The more glass they have, the more fragile they are, but actually the better optics you'll get as well. So, you know, they're not, not as good, but they're good enough. And once you get going, once you start using it and get confident, it's then, you know, you, you, you're using them enough to to justify spending more money.
So do they pay? Well, yeah, they do. So as well as rabbits, you can do dog nose, and I left out cats here too, so do cat noses too.
Do noses, dog ears, . If you live anywhere with grass, you can spend a happy summer removing grass seeds from all those places. So typically, I've been doing over the last few years, 12 to 20 nasal grass seeds a year, just our standard workload.
Give fact probably charge £300 a bit underestimate really, but we're probably about about that there. You know, that shows you you can really make those endoscopes pay for themselves, and then you did the rabbits on top of it. So these can work really hard and they want a very few bits of equipment I reckon they actually pay for themselves every single year.
So it, it's there, you can justify these things and they are very useful. So start with cheap, move on to the good stuff. Now with dental examination, again, you can actually do this conscious.
Now what's really useful with this is you can show the clients what's going on there, you know, you normally don't know to scope, which is fine. You can hold it in position and show, show the client, that means holding rabbit fairly fixed for a long time, which they don't like very much. It also tend to shift a bit and it's not very easy to show the client.
If you are using these little Bluetooth scopes, . And what I've used has been the Dr. Fritz one, but there are few, there are few about which which are which are good, much more robust.
Don't put your smartscope in a conscious rabbit mouth because those 2.7s are fragile. And if a rabbit bites on it, that is going to be the end of escape.
So be careful with that. So use, use one of these more robust, cheap escapes, Bluetooth escape ideal. And then you can just have your phone up and just show the client.
What's going on there, that's a really good way of explaining. And the other thing you get to is magnification, that's important. So here is a, it's actually a knee sized rabbit, but we can see this rabbit looks fairly normal there.
Now we move a cheek out away and you can start seeing little hooks here too, magnification on there. So that's really useful. That's gonna be painful, and we can explain that to the client about what we, what our target actually is and what we're doing, and that that's worth a picture paints 1000 words they say.
So we, we glue onto a pharynx for larynx, we can look at some snoring coughing case, and we do see those two. We do see case of laryngeal paralysis which may present us that, especially in some of giant rabbits, and we do see inflammation in those areas too. And of course, as mentioned, you go to intubation, so we'd avoid trauma and stuff.
And this is a video hopefully showing intubation through here. And obviously we've we know got there, we can move down or some liquid, by the way, that's perfectly normal. We put the scope into the into the larynx and then we just simply run the scope over, over the end of the scope and push it down there so the scope enters the larynx and then we push the tube over the top of it and we piggybacking that down there.
So it's quite useful. And you may see, so again we can see inflammation. This is a laryngeal paralysis we've got fairly normal focal fold on this side.
We can see the atrophy on this affected side here and hopefully now I'm gonna have to move forward here because a lot of preamble trying to get to the right place here and just show you a brief glimpse, this is a tough one to do. We can see the larynx here. I'm hoping that you get to see something in action.
This was a difficult one to scope. And again we can see here we've got the rabbits don't move very much at all. We've got a very brief glimpse there, hopefully that left one not moving in the least.
Sorry, it's not the easiest place to. What we can also do is we do see tracheal foreign bodies. And these are, in my experience, almost entirely, iatrogenic.
This is one of the big dangers in life, this is the endotracheal tracheal tube. If you're positioned slightly wrongly and it contacts the molars or if you don't intubate, sorry, remove a tube, quick enough after the procedure, sometimes they'll actually bite through the scope and then you're, you're going to end up with an inhalation and you've got to remove it. On the bright side, if you have your own scape, you can then go down and remove it yourself.
This is a tooth. I've seen 2 now. This is one that was referred where, They're doing a dental, and they clipped off a bit of tooth and it went straight down the trachea.
This is I'm gonna show a video of removing this, . The other one I've seen was more on my own, where I was removing a tooth from an abscess. I'd had a V gel in place.
I removed the V gel. I did intubate to replace it, and I had an open airway. It is remarkable in both cases how on earth a tooth can go straight down the trachea.
You can see the difficulty intubating it. It's difficult getting to that larynx there too, but believe me, bits of tooth have no trouble finding the larynx and the trachea. .
The referred case I they remove a tooth. I can show you the set my one I wasn't, and it's, you know, one of those things where if you take a message from this particular slide is, yeah, it's cool having the toys and doing things, but don't forget the basics. So whatever you do, don't leave in the airway unguarded if you're removing bits of tooth.
And this is removing it. It's oopsie, it's not. And this is just how fiddly it can be.
So here we go, we're down with trachea now, . Rabbits sedated using intravenous agents, and again, there's some liquid, and what we can do is we can now advancing our biopsy grabs. And one thing I remember is when you're using a 2.7 30 degree slope scope, you're not looking straight ahead.
So it's actually surprisingly difficult moving something straight using that. You're always looking slightly obliquely. So we're just gonna see this and we're going to grab.
And it slips And they push it, and it's Can be fiddling. Yeah, I know the result of this, and I still feel tense when I'm looking at this bit cause you are sweating a lot when you do this and grab it, fill it, drop a bit because I've got a curve on the trachea. That we can play the tricks and now we can actually pick it up and we're pulling, we just fiddle a bit and Drop it again.
And try and get a bit of a hook on this tooth. And this is the great moment when it just comes up and there we go and we drop it outside the body. Fantastic.
So you can do the things like that too, hopefully avoid your disasters, but when you have got a disaster, it gives you a means to get out of it, which is quite good. We have looked down the ears now. I very rarely use a scope conscious in rabbits, because we've often got corrumen and stuff, and you don't see much apart from corrumen, and then get a very dirty scope at the end of it.
But really useful when they're anaesthetized and we're done some initial clearing out too. I used for guiding a flash. And guided sampling, and if we're going to do myotomy and clear out mids and stuff, it's really useful to see what's going on there.
So here's some views of some fairly normal ears, this is a straight, straight headed rabbit, a pricky rabbit, we can see looking straight down, . It's remarkably hard seeing the eardrum, by the way, we can show a picture of eardrum in a second, but it's very hard. This is a normal crewman.
Please note the Karument and past look exactly the same. This is a lopid rabbit. We can see the fold across the ear here and really difficult to we're trying to look past this rumen here.
And this is the thing you can't redo conscious, because you've got to manoeuvre your scope through that and they don't like it. Once you've cleaned out, you get a better view. This is, and this is looking at the eardrum of a sort of fairly trad rabbit, .
And this is what you get when you get some material behind it. So if you've got mid ear problems, you may see it bulging outwards of the tympanum and we see how cloudy it is behind, and that's a bit of indication we've got some mid ear discharge. And then we can, we can pop a needle into there we or whatever we pop a sprawl needle through guided, and we can just pop that and we can take a sample out or flash.
So really useful, and we occasionally do actually get foreign bodies, and here is, here is a bit of grass. We can pop scopes in noses, as well, and this is where we can. Distinguish between discrete lesions, generalised inflammation, and if we've got unilateral discharge, we do occasionally see foreign bodies here as well, and sometimes some slightly more sinister lesions as well.
And this is a really good augmentation to X-ray in particular, where we may not get as much detail as we want looking at the nasal chambers. This allows us to do things like also like retrieve foreign bodies and of course we can biopsy and that's really useful. So in case like this we've got a lot of pussy discharge and some information we can grab a bit of nasal mucosa and we can remove it.
What else we can see, well, here we got a bit of a foreign body here. We can, we can grab hold of that and we take it out in one go, which is just great. And here's a bit of a tour around the nose, and we have a look here you can see it's really quite red, quite inflamed, got a lot of discharge through there, move around through that too.
It's a bit jerky because it's actually quite tough moving a rabbit nose. This is using a 2 millimetre scape, and we can see that all the areas are red, now seen inflamed and quite thickened, and those are not, not good good areas to be looking at. Before that occasion and We get back in again.
Again, we can start seeing some lesions too. And what we're doing is stage is just basically selecting where I'd want to take a biopsy from. And biopsying can take for culture, which is more valuable than taking discharges and swabs, and I can also take them for histopath and to have we got like an inflammatory rhinitis?
Have we got a a a direct infection, which will happen too. Move on to, so this moves us on to CT . CT is expensive.
I don't want to put a question mark there. It is expensive. Is it the best modality.
It's a really good modality for many areas of the head. There are areas where other bits are as good, or bits where it doesn't tell us as much detail. So we still want to do other bits too.
They are, as I said, expensive, and essentially they are 3D X-rays, which is a good, good way of looking at them. In terms of portability, machines are expensive, they do require space. Don't think the machine itself is your only expense too, for a lot of the conventional CT they can require special electrics.
They're gonna require additional shielding, so you need your RPA in to sign it off and to and to advise you on what you need to do for shielding. And they definitely, if you go, I think you getting CT, sign up to the most expensive maintenance contract you can. They do have a habit going wrong.
They do have a habit of extra heads and things like that blowing up, so you know, get your, your maintenance contract sorted out there, and that's probably the most expensive bit of the whole thing. So you get RPA requirements. And again, if you're not used to these, you're going to want to use one of these CT readers to look at this, which again will add costs onto each one you do, but regard it as CPD and you soon start picking up and learning to do it yourself.
So how many do you need to do to afford it? Well, most machines. Generally normal pricing, you're gonna need to do about 3 a week.
That sounds a lot, but actually, if you think about a case, you can use a CT4, that's not as many as you think it is. And it's actually surprisingly easy to easy to afford. What I've been using is a Vime game, and the picture you'll see will be taken from that.
It's not a true CT, it's a volumetric scanner. The disadvantages are it's quite slow compared to sort of a typical, CT unit, and so we didn't have to state or at leastize a lot more of the animals for it. And it will only do small small areas.
So we used basically with the volumetric scanner, we're taking a 12 by 12 centimetre block of tissue. What is good about it is that we don't need special electrics for it, so it's actually cheaper to set up and run. We get a lot less scatter with it, which is also helpful with the shielding requirements, but it gives amazing, amazing detail.
So it will give you detail down to about 90 microns, which is pretty much small. . It is also movable to an extent which is potentially has uses, we must know how many user use that particular use.
There are alternatives that you can get both new and secondhand machines. You can use some places where CT will offer outpatient imaging, and that's worth knowing about too. And this is one of the big advantages of corporate groups and stuff is that within an area, it's pretty likely that somebody in that group will have a CT, and that's a good way of piggybacking onto that and starting to send caseloads just for imaging, getting the images back and learning how to, how to read them.
And if you've got a good relationship with a, with a, a referral centre with those, again, you may be able to take cases, and help with the imaging itself. So there are ways of doing it and ways of accessing CT much more readily than they were a few years ago. So where does it score over X-ray?
Why can't I just do a lot of X-rays? Detail is a big thing. So for example, we'll look at some pictures of nasal turbinates.
You can't really see those properly on X-ray, you can on these. We can identify fluids and soft structures which we can't often do easily on X-ray unless there's a lot of them. So sinuses, we can look at middle and inner ear, which is great, and we can, to an extent look at brain.
CT isn't brilliant for brain, we've got a big lesion, it will do it. So slightly outside the remit of this talk is you can actually look for rat brain tumours quite nicely with it. It takes away overlay issues because it's 3 dimensional, so we can do these like conducts both in one go and get great detail on those.
We can look at the temporomandibular joints really easily too. And because we get 3 dimensional views, we can start doing some really good surgical planning, and for abscess surgery, that's fantastic. It also takes away some of the issues with positioning.
Now, this is slightly of contention. It's a bit like taking any sort of digital, photograph is if you don't take the image properly, you can adapt it and change it, but actually, it's not as good as taking a good image in the first place. Good positioning really helps a lot, and the more positioning you do, the better.
But you will, I said, with single head tilt cases. Not be able to get a straight image with dental labs it's very hard when you've got a big lump on the bottom of the jaw to get that that jaw straight. So at least with this, you can manoeuvre and manipulate the images quite well afterwards if you can't get them perfectly straight.
So that is quite useful for some of these, these things too. So I'm gonna start with some of the cases where there's potentially less difference between the X-ray and CT, and the big examples is dental cases. There's a nice paper piece a few years ago where people looking about CT and dental, dental radiographs tended to find that the dental radiographs were a little bit more diagnostic.
Now that might be just much more experienced looking at them, but there's a good panel of experts who look through those. So there is In terms of looking at dental routes, probably not enough difference to really fully justify getting a CT unit. But again, we can see lots with them.
We can see the hooks quite nicely, which is quite cool, but we can look at those directly anyway, and we can see where the roots go and what they're doing with that. Again, you can see the turbinate detail through here, which is always cool. We can do different types of you.
So this is where I'm sort of if you like using, quite thick slices, look, get a whole block of, teeth, and we can see really good, detail on what those, tooth roots are actually doing there. So this is a nice sort of grade 3 to 4 disease we can see the, The doming of these upper motor roots, we can see the displaying of the lower motor roots, and we see a lot of reaction of the bone around them. And we can go to 3D as well, we can start seeing those two roots sticking up into the back of the eye here and stuff.
So again, really useful. We can have a look at the insides for our overgrowth as well. And this is what I'm talking about with breaks and stuff is that very commonly, I think a lot of these juveniles have actually run into something and we get a little break just in here, just have the teeth and you see it's almost like shunted down.
And I think that's what the primary lesion all these is if you get a little little micro fracture of the palatine bone there, and this, this change in position. There's a treatment, not particularly, but I think it's quite interesting. And again, I think this may mean that a lot of these in sizesor, .
Misshape or mapositioning is not so much due to a congenital problem, which is just a breeding issue, but probably a lot more down to frightened rabbits who haven't been socialised and are running about doing silly things and running into stuff. Which puts a different emphasis on prevention. Abscess surgery again, lovely to do.
We can see the abscess quite clearly. We can start looking where it in different arcades for prognostics, can see very, very obviously too. In this case here we can see this big abscess here behind and we haven't actually got a tooth actually involved with it, but we can see how it's distorting the teeth.
It probably did have a tooth involved originally, and we can know where the areas we've got to remove, we can see extension into these bits here. So we're gonna have to take out these teeth. And, and to get it under control.
And if we really want to view in line of postage property, we do a 3D view and we can start seeing, see the bony hypertrophy here. We can see the area where bone's been removed and we can really see exactly how we can plan and and actually visualise our surgery before we go in there so we know exactly what we're doing before we anaesthetize a rabbit. Fantastic for retrobal abs.
I mean, this is something which I find X-ray can't do. And although ultrasound lets us see the abscess, what it doesn't do very well is actually see how many teeth are involved and stuff. But we can see this really really nicely with these.
So here's our nice bulgy eye. Here is our soft tissue behind the eye. Changing the weighting of of the image, we can really see exactly what we're getting there and what our problem is.
More extreme case, this is one where I don't think we necessarily need a CT to diagnose this, and this is one of a nice case where she's breaking out into the, side of her face. I think we see the eye might have been bulging a little at that point. I want to put a picture in here.
the mandibular fracture is fantastic. They do happen. They're not common.
I have got an image, so I just couldn't find it in time for this talk, I'm afraid. But if you are suspecting this because of the overlay issues, CT is just fantastic for, for mandibular fractures. Now the cases where we have a big, big advantage over over radiographing.
These lads we can start with those. You can put it down both, we can visualise both at the same time, and it's lovely. We can see the flow of the material through here.
It's started up here. We have to go through slice by slice. We can see a little bit of pooling in this area here too, and we can put the 3D together.
The contour shows much whiter than bones so we can see it moving through here. You see how complicated that is too. So it's really great for doing different things too.
Nice thing with these so we can start taking bone away which is left with the shape of a duck's too, which is good. And we can see where we got the potential blockage and potential issues here. So in this case here we've obviously got disastrous teeth, but we can put the contrast in, we can see at this first.
Second, molars are what's causing a problem. We can tell it's not blocked because it's going on beyond that, but probably getting some stenosis of the duct around there. And in this case we've actually got a sinus problem, we said that this rabbit had a right sided blockage and discharge from the eye.
The left side wasn't too bad, but we can see we've got a little lesion here which is really, really restricting flow, and this is in the sinuses. We can actually see you've got a little osteomyelitis in that bone on the lateral side of the maxillary sinus. So here we've got a sinus problem we need to address it's from the sinuses.
Here, if we could, this would be a dental, case, this would be just sinus flushing. We can look at a temporal mandibular joint, which is fantastic, and again we take slices through here. We see nice normal joints here too.
We may see some reaction here. So again, much clearer imaging, you know, it doesn't require a lot of imagination to see exactly what's going on with those cases and where we need to, to address. Looking with sinuses and cells, .
Slightly jumping back and forth here again, you can compare direct anatomy much easier than slicing through rabbits nose as part of examination. This is dorsal recessessed by the maxillary sinus you see on the other side too. And again, we can see it's beautifully on the CT, except in this case we've got discharge through both recesses and a little bit of bone, information on the other side too, and we can see our turbulences which are fairly nice there so we've got discharge coming out into.
The, nasal chambers too, which is why this rabbit is very snotty, getting the air trapped in some places too, a bit of a thing we've got discharged there. So looking at, further sinus cases here, we can see here we've got the ventral recess of the maxillary sinus filled with fluid with the material here. We can see the dorsal is clear, .
This shows progression to both recesses of the of the sinus, and we can see there's bone destruction as well on the lateral wall here between the two parts. And we got discharge, discharge entering into the nasal cavities, and we've got some bone destruction here on the, left side. Further, progression again we can see much more.
Discharge. Much more bone destruction, and, much less clear demarcation of the sinuses. And we can see progression here too where we also got obliteration of the nasal cavity just filled with material.
Now these are cases where actually even endoscopy doesn't work very well because there's so much stuff in there, you can't see past it with the scope. So these are absolutely invaluable for, for being able to sample and see what's going on. But most importantly, this bit here too, you can see got no bone, particularly.
And we can look in different planes as well. Here we're looking at coronal sections and we can see through here we can see, we can see the extent to which this side is affected. Here we've got air in the maxillary sinus still, and here we've got all that air area is is filled up with discharge.
So very, very useful. Indeed, and we start seeing teeth involved. We can start seeing, you know, what the prognosis, what we're gonna need to do.
Is this gonna be a case where we can treat medically, is in a case where we can flush? I a case where we have to actually open up the sinus and, and physically remove some of that material. So that's where it really helps.
Now, where there's absolutely no competition, these sort of cases, so we look at nasal cavity. This is a radiograph of a case that was referred to me many years ago. A lovely radiograph and we can get suspicion of this nasal discharge case that there's something happening within here, doesn't look clear in airfield.
When we've put through a CT, we can see we've got this massive lesion here, a lot of disruption, the, there's no midline bone anymore, and this is a, this is a tumour, and, adenocarcinomas, adenomas of the nose are not rare in rabbits. We can start seeing change in the bone here too. Again, we've got the sinuses, we've got, we can see some air block fillings here.
We've got some, we've got some discharge here too, and we can start seeing changes in the bone. So chronic inflammation, we can see we've got bony changes within that too. So we've got some idea of chronicity from that.
We can, this is a very recent case, and again we've got a very focal area to this rabbit had bilateral discharge, but the left is much worse than right and we can see we got these. There is this, this one area where we've got bone destruction, nice turbances here, not on here. We've got chronic inflammation here too.
And this really helps us then get the endoscope out and know exactly where we're going to biopsy and sample. This is a bacterial rhinitis in that area. Some's actually, if something so, so small, we remove them you do quite a lot, a lot of, lot of good.
It's brilliant for, for, for head tilt case if we find other causes apart from middle ear occasionally. This was a trauma case, this poor rabbit had an argument with a folding bed. We can see he's actually got a bit of a fracture, of this side of his skull.
When we see when across there, we can see the buller has been fractured through here. We can see that with 3D as well. We can see a cleft here.
And this is not corromen or, or pus. This is actually blood inside the middle ear. Sadly's case didn't do so well for obvious reasons.
We can also visualise the inner ear, so we know the externals here, which is the middle ear and here is the inner ear here, which is a bit thickened but relatively normal, but we can see contrast this side or we can see extensive destruction of some of the to the parts there, and this is showing us we have got a true Tyson Turner here and obviously that's going to affect how we manage it, how we give a prognosis and stuff. This case, again, head tilt to the left hand side. But we're actually looking at discharge in both sides.
But what we can see a difference is the wall of the inner area there is intact, is broken here. So you're getting quite subtle lesions here and we're able to diagnose that Otis in turner which on radiography just would not be possible. We can pick up brain lesions.
I'm cheating like mad here. Neither of these are a rabbit. They are very unusual in rabbits.
But this is a tumour here, and this is extension of of inner ear infection into, probably a localised meningitis, encephalitis type thing. So we can see those if we want to. Most commonly though, we're dealing with middle and external disease, and I just want to introduce you.
This is the, grading scale that, was developed by Edinburgh University a couple of years ago and published in, I think it's JSAP maybe in that record, but it's published, it's really useful to what we use. And so we can start with grade one as, as before. So this is the external on the left, middle on the right.
So here we can see we've got material in the external area. Got no bulging. We have got an intact, tympanum.
On grade one and middle ear, again we've got nothing in the external here too, but most important, we got a little bit of discharge, we've still got part of a bullet that's clear. Grade 2 Externally we're getting a little bit of a bulge, vis a vis ear will diverticully you get lopi rabbits, it's starting some bulging from there. A again tympanum is intact.
Mid grade two middle ear, again we're getting filling of the buller completely, we're getting no bony changes. For grade 3 external, we're getting the immer is still intact, but it's being to be forced inside this bulging and being pushed into the tympanum and we've got some bulging of external ear canal. With the middle ear for grade 3, we're getting changes in the bullet, we're getting some thickening, we're getting some thinning of the bone, we're getting change of shape and size.
And I say we get grade 4 for the externally, we're getting this very big oral diverticulum here, with ear-base swelling. Again, the tympanum is still intact. And for the middle ear, basically we've now got buller disruption, osteomyelitis, and this is one of one case where it can become a true ear-based abscess where we've got material entry in surrounding tissues.
And these are the ones where we would not flush the ear because we start putting saline. Down here cleaning out that this area here, then we're going to start getting issues with, with, with infection and cellulitis entering these areas. These are ones where we're probably gonna do anything, we start doing, partial total ear canal, ablations and actually marsupializing that as, as before.
So for ears, the CT is absolutely invaluable for staging the disease, for issuing prognosis, for helping guide you with a route to management. And as you know, ear disease and rabbits is extremely common. So in summary, there are a range of diseases of rabbit head that require a range of different imaging solutions.
As a result, you often need more than one different imaging modality for each case. I hope also illustrated that although some of these are expensive, they often maybe a bit more affordable than you can think, and there are ways around it. But also, if you're part of a group or you've got a very, you've got a friendly referral centre, there is access to this type of thing.
Probably easier than you may imagine. And once you know the indications and where it's gonna benefit the patient, that can be really very useful indeed. So it's, you know, hopefully the end of this.
Give you some idea of what's possible, what you can achieve from what's possible, and therefore hope that might help with with achieving what you can offer to the patient in each case. Thank you for listening.
