Surgical Diseases of the Upper Airways. Michael Huber DVM, MS Diplomate American College of Veterinary Surgeons
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1 Surgical Diseases of the Upper Airways Michael Huber DVM, MS Diplomate American College of Veterinary Surgeons
2 Surgical Diseases of the Upper Airways General Considerations Brachycephalic Syndrome Laryngeal Paralaysis
3 General Considerations Anesthesia Antibiotics Postoperative Management Complications
4 Anesthesia Extreme risk Induction/recovery Minimize restraint / stress Preoxygenation Rapid induction intubation Avoid opioids which promote vomiting/ regurgitation
5 Antibiotics Prophylactic usually recommended If airway penetrated then therapeutic
6 Close monitoring Intubated as long as possible Supplemental oxygen Minimize excitement/pain Postoperative Management
7 Complications Acute respiratory obstruction Aspiration pneumonia
8 Brachycephalic Syndrome
9 Brachycephalic Syndrome Components 1. Stenotic nares 2. Elongated soft palate 3. Everted laryngeal saccules 4. Laryngeal collapse/stenosis
10 Pathophysiology Stenotic nares Elongation of soft palate Eversion laryngeal saccules Edema & inflammation Distortion pharyngeal tissue LARYNGEAL COLLAPSE
11 Laryngeal Collapse
12 Pathophysiology Gastrointestinal lesions inspiratory effort low negative intrathoracic pressure gastroesophageal reflux/hiatal hernia Esophagitis 83% Chronic gastritis 98%
13 Epidemiology Brachycephalic breeds Bulldogs Boston Terriers Pugs Pekinese Shih Tzu Boxer Mean age 2-4 years
14 Presenting Complaint Noisy, stridorous breathing Exacerbated by exercise, stress, heat Varying respiratory distress Concurrent GI signs Dysphagia Ptyalism Regurgiation / vomiting
15 Physical Exam Stertor Inspiratory stridor Orthopneic posture Restless/anxious Hyperthermia Stenotic nares
16 Diagnostic Plan Visual inspection of face Radiograph of neck AND thorax Laryngeal exam BE PREPARED FOR TRACHEOSTOMY
17 Radiographs Noncardiogenic pulmonary edema Aspiration pneumonia Hypoplastic trachea
18 Medical Management Weight loss Exercise restriction and environmental modifications Anti-inflammatory dose steroids
19 Stenotic Nares Thickened and collapsed dorsolateral nasal cartilages obstruct airflow Causes secondary airway collapse due to negative pressure generation 50% of cases
20 Vertical wedge Rhinoplasty
21 Punch resection alaplasty Rhinoplasty
22 Punch resection alaplasty Rhinoplasty
23 Punch resection alaplasty Rhinoplasty
24 Elongated Soft Palate Soft palate should not extend beyond tip of epiglottis Neutral position, without ET tube Resection to level of caudal 1/3 of tonsillar crypt % of cases
25 Elongated Soft Palate
26 Traditional Staphylectomy
27 CO 2 Staphylectomy
28 Everted Laryngeal Saccules Result from prolonged upper airway obstruction Tissue just cranial to vocal folds pulled into ventral glottis First stage of laryngeal collapse 40-60% of cases
29 Everted Laryngeal Saccules
30 Everted Laryngeal Saccules
31 Complications Pharyngeal edema Nasal regurgitation Aspiration pneumonia Dehiscence of rhinoplasty Voice change Persistent upper airway noise
32 Laryngeal Paralysis
33 Laryngeal Paralysis Failure of one or both arytenoid cartilages to abduct during inspiration
34 Epidemiology Congenital/Inherited Siberian Huskies (USA) Bovier des Flandres (Netherlands) Bull Terriers (Britian) White-coated GSD <1 year of age
35 Epidemiology Congenital Laryngeal Paralysis- Polyneuropathy Complex Dalmatians Rotties Leonbergers Pyrenean Mountain Dogs
36 Epidemiology Acquired Geriatric (>9 years) Large and giant-breed dogs Labs, Goldens, St. Bernards, Newfies, Irish Setters Males > Females (3:1)
37 Congenital ( < 1 year of age) Acquired Trauma / Iatrogenic Compression Hypothyroidism Pathophysiology
38 Pathophysiology Idiopathic Progressive, non inflammatory, degenerative disease Manifestation of polyneuropathy
39 Pathophysiology Manifestation of polyneuropathy Lahue % paresis Jeffrey 2006 EMG & neuro abnormalities in all dogs Theiman 2007 LMN all dogs within 2 yrs atrophy cranial tibial m. and peroneal n. Stanley 2010 abnormal cervical and cranial thoracic esophageal motility
40 History Voice change Loud breathing Coughing/gagging Exercise intolerance Dysphagia Regurgitation Severe dyspnea Cyanosis Syncope Exercise Obesity Excitement Warmer weather
41 Source: Griffin and Krahwinkel, Compendium 2005 Clinical Signs
42 Physical Exam Stridor Referred upper airway sounds +/- Fever +/- Pulmonary crackles Respiratory distress
43 Diagnostic Testing Neurologic examination Ataxia Pelvic limb CP deficits Decreased postural reactions
44 Diagnostic Testing CBC unremarkable Chemistry unremarkable cholesterol/lipid/les Free T4 +/- ctsh 30-40% of cases
45 Diagnostic Testing Thoracic radiographs Aspiration pneumonia 7-10% Megaesophagus
46 Radiographs
47 Diagnostic Testing Laryngeal examination Rigid laryngoscope Preoxgenate Propofol mg/kg to effect
48 Diagnostic Testing Laryngeal examination Cartilages in paramedian position NO abduction during inspiration Dopram 2.2 mg/kg IV Rule-out laryngeal mass DON T confuse PARADOXICAL movement
49 Laryngeal Collapse
50 Treatment Options Emergency management Oxygen Sedation Acepromazine 0.02mg/kg IV Butorphanol 0.4 mg/kg IV Anti-inflammatory steroids External cooling if hyperthermic Temporary tracheostomy
51 Treatment Options Medical management mild clinical signs Weight loss Cool environment Low stress Harness Exercise restriction +/- steroids if laryngeal edema
52 Treatment Options Surgical Management Ventriculocordectomy Partial laryngectomy Unilateral arytenoid lateralization Permanent tracheostomy
53 Ventriculocordectomy
54 Partial Laryngectomy
55 Unilateral Arytenoid Lateralization
56 Unilateral Arytenoid Lateralization
57 Permanent Tracheostomy
58 Close monitoring in ICU Soft food in meatball form Feed from ground Metoclopramide +/- Antibiotics +/- Sedatives Postoperative Management
59 Complications Aspiration pneumonia 8-33% Coughing / gagging 16% Return of clinical signs 4-8% Respiratory distress 2-4% Sudden death 3%
60 Prognosis 90% of dogs Reduced respiratory signs Increased exercise tolerance Majority of owners report Improvement in QOL Satisfied with decision to do surgery
61 Summary Brachycephalic Syndrome Multiple components Progressive Can lead to respiratory distress Concurrent GI disease common Surgical management early in disease Critical anesthesia patients
62 Summary Laryngeal Paralysis Common and important cause of URT obstruction in dogs Thorough evaluation for concurrent disease Medical management with mild signs Surgical management when more severe or with decreased quality of life Lifelong aspiration pneumonia risk
63 Thanks!
64
65 Inspiratory Stridor
66 Respiratory Distress
67 Normal Laryngeal Exam
68 Laryngeal Paralysis
69 Larynx Anatomy
70 Staphylectomy
71
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