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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
Sedated Laryngeal Exam
Doxopram – 1mg/kg IV
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Sedated Laryngeal Exam
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%
3 year survival – 84%
4 year survival – 75%
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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Brachycephalic Syndrome
Components Stenotic nares
Elongated soft palate
Everted saccules
Hypoplastic trachea
Laryngeal collapse
Everted tonsils
Brachycephalic Syndrome
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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Brachycephalic Syndrome
History Heat and exercise intolerant
Stertor
Snores
Sleep apnea like signs
Respiratory crisis
Regurgitation
Brachycephalic Syndrome
Physical exam Stenotic nares
Stertor
Obesity
Inspiratory dyspnea
Brachycephalic Syndrome
Diagnostics Thoracic radiographs
CBC/Chemistry?
PT/aPTT (especially if hyperthermic)
Sedated laryngeal exam
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Brachycephalic Syndrome
Treatment – non emergent Weight loss
Avoid hot and humid situations
Harness
Brachycephalic Syndrome
Treatment – emergent Oxygen supplementation
Light sedation
Body temperature management
Judicious IV fluids
Anti-inflammatory corticosteroids Dexamethasone SP 0.1mg/kg
Intubation
Temporary tracheostomy
Brachycephalic Syndrome
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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Brachycephalic Syndrome
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
Brachycephalic Syndrome
Complications Nasal bleeding
Dyspnea, upper airway obstruction
Aspiration pneumonia
Dysphagia
Brachycephalic Syndrome
Prognosis Successful outcome – 94.2%
Excellent outcome 50%
Perioperative mortality – 3%
Riecks et al, JAVMA 2007
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Temporary Tracheostomy
Indications Upper airway obstruction
Upper airway surgery
Anesthesia when unable to orotracheal intubate
Long term mechanical ventilation
Temporary Tracheostomy
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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Temporary Tracheostomy
Tube options Cannulated vs. non cannulated
Cuffed vs. non cuffed
Oxygen/suction channel vs. non
Commercial vs. home-made
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Temporary Tracheostomy
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
Temporary Tracheostomy
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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Temporary Tracheostomy
Post placement management Close monitoring
Oxygen supplementation
Changing of the cannula
Suctioning
Nebulizing/humidifying
Temporary Tracheostomy
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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