Upper Respiratory Surgical Conditions - Dogs And Cats ... · DOGS AND CATS VETERINARY REFERRAL BOWIE, MD APRIL 17, 2016 Overview Anatomy Review Laryngeal Paralysis Brachycephalic

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Upper Respiratory Surgical ConditionsSTEVE GARNETT, DVM, DACVS-SADOGS AND CATS VETERINARY REFERRALBOWIE, MDAPRIL 17, 2016

Overview

Anatomy Review

Laryngeal Paralysis

Brachycephalic Syndrome

Temporary Tracheostomy

Anatomy Review

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Laryngeal Paralysis

Causes Congenital

Early onset – demyelination and axonal loss of long nerves

Endocrinopathy

Myesthenia gravis

Neoplasia

Trauma

Geriatric onset laryngeal paralysis and polyneuropathy - GOLPP

Laryngeal Paralysis

Signalment Congenital

Bouviers des Flandrs, Husky breeds

Early Onset Dalmations, Rottweilers, White coated GSD, Pyrenean Mountain Dogs

Acquired >10 years old

Large breed

Males have possible predilection

Laryngeal Paralysis

History Usually progressive

Inspiratory dyspnea

Stridor

Heat intolerant

Change in bark

Evidence of pneumonia

Dysphagia – pararecurrent laryngeal nerves to cranial thoracic and cervical esophagus

Hind limb weakness

Stanley et al, Vet Surg 2010Andrade et al, Vet Surg 2015

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Laryngeal Paralysis

Physical Exam Mild stridor to respiratory crisis

Thorough cervical palpation

Paraparesis

Hypersalivation

Harsh lung sounds, crackles – pneumonia

Laryngeal Paralysis

Mild/early cases Diagnostics

CBC, Chemistry, T4

Possible resting cortisol or ACTH stim, Ach esterase titers

Thoracic and cervical radiographs

Esophagram (owner education vs. change in recommendations?)

Sedated laryngeal exam Propofol only - SLOW

Paradoxical arytenoid movement

Doxopram 1mg/kg IV PRN to supplement diagnosis

Laryngeal Paralysis

Mild/Early Cases Treatment

OWNER EDUCATION

Weight loss

Change to a harness

Avoid stressful or hot/humid situations

Anxiolytics or sedation PRN – trazodone or acepromazine

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Laryngeal Paralysis

Severe cases Emergent treatment

Oxygen supplementation

Body temperature regulation

IV fluids

Sedation

Prokinetics

+/- anti-inflammatory corticosteroids (<0.1mg/kg Dex SP)

+/- intubation

Laryngeal Paralysis

Laryngeal Paralysis

Acepromazine0.01mg/kg

Butorphenol0.1mg/kg

Give IV

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Laryngeal Paralysis

Severe cases Diagnostics

CBC, serum chemistry

Thoracic and cervical radiographs

Sedated laryngeal exam

+/- PT/aPTT

Sedated Laryngeal Exam


Doxopram – 1mg/kg IV

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Laryngeal Paralysis

Surgical options Unilateral arytenoid lateralization

Bilateral arytenoid lateralization

Partial laryngectomy

Castellated laryngofissure

Permanent tracheostomy

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Laryngeal Paralysis

Post operative care NPO for 24 hours, then canned food meatballs for 2 weeks

Long term dietary modifications

Activity restriction for 2 weeks

Consider antacids and prokinetics

Harness

Limited post op sedation and opiods

Lifelong monitoring for pneumonia

Laryngeal Paralysis

Complications Aspiration pneumonia (20-25%)

Recurrence (5-10%) Immediately post op to several years later

Death (3-10% w/in two weeks of surgery)

Unresolved coughing or gagging (23%)

Incision complications (7-10%)

Change in phonation

Laryngeal webbing

Hammel et al, JAVMA 2006

Laryngeal Paralysis

Increased risk of complications Bilateral simultaneous procedures Increasing age Pre- and post operative megaesophagus Temporary tracheostomy

Increased risk of death Bilateral simultaneous procedures Increasing age Partial laryngectomy Post operative megaesophagus Temporary tracheostomy

MacPhail et al, JAVMA 2001

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Laryngeal Paralysis

Increased risk of aspiration pneumonia Post operative megaesophagus

Post operative administration of opiods

Wilson et al, JAVMA 2016

Aspiration Pneumonia

Laryngeal Paralysis

Prognosis Median survival time with surgery – 365-1800 days

1 year survival – 94

2 year survival – 89%



90% of owners report an improved quality of life

MacPhail et al, JAVMA 2001Wilson et al, JAVMA 2016

Hammel et al, JAVMA 2006

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Components Stenotic nares

Elongated soft palate

Everted saccules

Hypoplastic trachea

Laryngeal collapse

Everted tonsils


Cause Congenital

Progression over time due to subatmospheric pressure within airway

Signalment English bulldog, Pug, French bulldog, Boston Terrier

All ages, but become more clinical with time

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History Heat and exercise intolerant

Stertor

Snores

Sleep apnea like signs

Respiratory crisis

Regurgitation


Physical exam Stenotic nares

Stertor

Obesity

Inspiratory dyspnea


Diagnostics Thoracic radiographs

CBC/Chemistry?

PT/aPTT (especially if hyperthermic)

Sedated laryngeal exam

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Treatment – non emergent Weight loss

Avoid hot and humid situations

Harness


Treatment – emergent Oxygen supplementation

Light sedation

Body temperature management

Judicious IV fluids

Anti-inflammatory corticosteroids Dexamethasone SP 0.1mg/kg

Intubation

Temporary tracheostomy


Surgical therapy Nasoplasty

Staphylectomy

Saccule resection

+/- tonsillectomy

Temporary tracheostomy

Permanent tracheostomy

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https://en.wikipedia.org/wiki/Stenotic_nares

http://www.animalcarecentergranville.com/Pages/Veterinary_Services/Surgery/

www.jaaha.org

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Huck et al, JAAHA 2008

www.andersonvet.com

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Post operative care Extubate as late as possible

Keep sternal with head elevated

Avoid over sedation, opiods

+/- oxygen supplementation Flow by vs. nasotracheal catheter

Prokinetics

Monitor for pneumonia


Complications Nasal bleeding

Dyspnea, upper airway obstruction

Aspiration pneumonia

Dysphagia


Prognosis Successful outcome – 94.2%

Excellent outcome 50%

Perioperative mortality – 3%

Riecks et al, JAVMA 2007

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Indications Upper airway obstruction

Upper airway surgery

Anesthesia when unable to orotracheal intubate

Long term mechanical ventilation


Procedure Clip and scrub

Midline incision from cricoid to mid cervical region

Retraction helpful

Split the muscles on midline

Incise between tracheal rings, no more than 50% circumference

Place stay sutures

Place tube

Close ends of incisions if needed

Secure around neck

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Tube options Cannulated vs. non cannulated

Cuffed vs. non cuffed

Oxygen/suction channel vs. non

Commercial vs. home-made

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Items Required• Appropriate type and size tracheostomy tube � Alternatively, standard endotracheal (ET) tube fashioned into tracheostomy tube, one size smaller than for ET intubation• Appropriate-size ET tube for ET intubation, with cuff syringe• Clippers with clean blade• Surgical scrub supplies• Barrier drapes• Sterile surgical gloves• Sterile gauze• Surgical instruments• Suture material• Umbilical tape• Assistant• Suction capability• Oxygen/standard anesthetic supplies and equipment


Instruments Two towel clamps

Scalpel handle and blade

Thumb forceps

Metz

Needle holders

2 mosquito hemostats

Suture scissors

2 Gelpis

2-0 silk, 3-0 PDS, 3-0 nylon

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Post placement management Close monitoring

Oxygen supplementation

Changing of the cannula

Suctioning

Nebulizing/humidifying


Complications Mucus formation - occlusion

Dyspnea

Coughing the tube out

Infection

Drainage

Stricture/granulation tissue formation

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Summary

Laryngeal paralysis is progressive and most dogs benefit from surgery

Brachycephalic syndrome should be discussed with owners early on and surgery considered early in life (before becoming clinical) in hopes of avoiding a crisis and/or laryngeal collapse

Temporary tracheostomy requires few instruments, is technically simple and can be life saving

Questions?

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Upper Respiratory Surgical Conditions - Dogs And Cats ... · DOGS AND CATS VETERINARY REFERRAL BOWIE, MD APRIL 17, 2016 Overview Anatomy Review Laryngeal Paralysis Brachycephalic