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54 terms

Sx E2 #35 Upper Airway Sx

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Which dogs are susceptible to Brachycephalic Airway Syndrome?
Bulldogs, pugs, boston terriers
What components exist to Brachycephalic Airway Syndrome
Primary Components (elongated soft palate 87-100%, stenotic nares 42-58%, tracheal hypoplasia)
Secondary components - develop over time
(Everted laryngeal saccules 59%, laryngeal collapse 53%)
What is a sign of end stage ariway disease
Laryngeal collapse
What are clinical signs of Brachycephalic Airway Syndrome?
Dyspnea
Stertortuous breath - snorting sound
Heat/Exercise Intolerance
Cyanosis
Collapse
DX Brachycephalic Airway Syndrome?
Breed, history
Exam findings
Rads of neck/thorax
Laryngoscopy
Stenotic nares - what do you do for them?
Take out a wedge of tissue in the nostirle and suture it up
Two surgical options for stenotic nares?
Horizontal or vertical wedges
Try to make it right first time - will bleed a lot
Owners will get annoyed with color change that will happen
Try to make it look the same on each side.
Elongated soft palate
How long should it be?
How long is it?
What else is it?
Soft palate should just reach tip of epiglottis
An elongated palate occupies part of glottic opening and may hang in rima glottidis.
Usually inflamed & thickened.
What proceedure corrects an elongated soft palate?
staphylectomy
Warning w/staphlectomy:
may need to perform a?
Due to post-op what or what?
Consider use of ____ to do what?
May need to perform temporary tracheostomy.(hole into neck for windpipe)
If post-op swelling & edema. consider use of NSAIDS OR OR OR IV steroidsl
Facilitate access to oral cavity.
How do you prepare a patient for a staphylectomy?
Position?
head and neck?
Prep with?
Sternal recumbency
Gag
Head & neck suspended
Paryngeal pack
Prep with dilute provodone iodine.
staphylectomy Identify the caudal border of the soft palate
Place what at resection location?
= just past caudal border of tonsils
Place stay sutures in palate at level of resection.
staphylectomy Cut the palate how?
Halfway across palate with Metzenbaum scissors.
(after cut 1/2 staphylectomy ) Then ID oral & nasal mucosa
Start at what end and do what?
Sew oral to nasal mucosa together, continuous pattern, with absorbable suture (Monocryl).
Then what (after cut and sew 1/2staphylectomy ) staphy
Transect remaining half of palate.
Finish sutureing
Assess length.
Watch for hemorrhage.
Remove pharyngeal pack.
What type of monitoring post staphylectomy?
24 hour intensive care
Hemorrhage, dyspnea, coughing, gagging, vomiting.
Is the problem with staphlectomy the surgery?
no, its the 24 hour care after that is often not available.
What is the first stage of laryngeal collapse?
everted laryngeal saccules
What do everted laryngeal saccules look like?
grape sized glistening balls just behind arytenoids
1 time laryngoscope is ok on the epiglottis
What is the pathogenesis of brachycephalic airway disease that leads to distortion and collapse?
Starts with elongated palate, stenotic nares & everted saccules -->
--> abnormal stresses w/in larynx
--> loss of supporting functional laryngeal cartilages
--> distortion and collapse
T/F Laryngeal collapse is static
False
it is progressive and worsens over time
Laryngeal collapse can result in ?
Amenable to surgery?
Result in: severe upper airway obstruction & pulmonary edema
If not amenable to surgery --> do permanent tracheostomy
When is a temporary tracheostomy indicated?
For bypassing upper airway obstruction
FB, laryngeal injuries
Tumors
Nasomaxillary trauma
Anesthesia during upper airway surgery
How is a temporary tracheostomy done?
Dorsal recumbency
Ventral Midline
Situate incision away from larynx & thoracic inlet
5th -6th interspace
Variety of techniques
Which muscle are you inserting the tracheostomy through? how do you find it?
Which muscle is confusing?
Sternohyoideus
Place finger on midline, push down, will see trachea unless not on midline
Platysmus is right under skin, and runs in all different directions = confusing.
Temporary tracheostomy:
How big should your cut be?
What helps?
no more than 50% of trachea
2 stay sutures - cranial and caudal to pull open and place trach tube.
After tube - secure with ties!
What management is necessary for tracheostomy?
Clean regulary
Removable canula helpful
Humidify & suction - instil 0.5-5mls saline q2hrs = 24hr care, can't go home
Clean around tube
ABX
Tracheostomy complications?
Dislodgement, obstruction, SC emphysema, Pneumomediastinum Pneumothroax, (air = rare) aspiration, infection

Long term: granulation tissue at site, tracheal stenosis
When is permanen tracheostomy indicated?
Larngeal collapse or neoplasia
How is a permanent tracheostomy performed?
Remove 3-4 rings & 50% circumference
Suture mucosa to skin.
What is a misconception about permanent tracheostomies for owners?
It does not mean a tube.
What do you need to try to prevent with permanent tracheostomy?
Prevent granulation tissue to prevent scaring.
Post op tracehostomy:
Bark?
What might cause occlusion?
Changed or absent bark - hoarse sounding
Stromal occlusion - mucus, skin folds stenosis
When doing tracheostomy what should you consider?
They all srhink - make it big!
What should the owner be told with animals wihtt tracheostomy?
At risk for inhaling things - no running through fields, swimming, be careful when bathing.
How many cartilages make up the larynx?
5
What are the 5 cartilages of the larynx?
Epiglottis
Cricoid = most caudal
Thyroid - most lateral and paired
Arytenoids - also paired, and burried under thyroid
What is the important muscle of the larynx?
What is it's important function?
What innervates it?
What do diseases that interfere with innervation of CAD do?
Cricoarytenoideus dorsalis
Opens arytenoids when inspire
Innervated by caudal laryngeal nerve - terminal segment off recurrent laryngeal nerve
Dz - prevents effective dilation of glottis
What innervates the cricoarytenoideus dorsalis?
Caudal laryngeal nerve (terminal segment of recurrent laryngeal nerve)
What can cause laryngeal paralysis?
Idiopathic degeneration = most common
Congenital
Trauma/iatrogenic
Neoplasia
Idiopathic degeneration leading to Lar Par is a sign of?
Generalized Polyneuropathy
can also be geriatric onset laryngeal paralysis polyneuropathy GOLPP
What breeds are at risk for lar par?
Bouvier, Husky, dalmation
Dogs with idopathic paralyisis start showing signs when?
Which breeds?
Mid-late stage of life
Labs, Afghans, Irish Setters, Goldens, Irish Wolfhounds
What are C/S of idiopathic paralysis?
-inspiratory stridor
-decreased exercise tolerance
-cyanosis & collapse
-change in bark
-gagging
-coughing
-generalized polyneuropathy
-esophageal dysfunction (consider esophagram)
often worse in summer
DX idiopathic paralysis
Ascult larynx
Thoracic rads on aspiration
Visual inspection under Light GA
IV thiopental best choice, no longer available - propofol can also be used, but be careful depth of anesthesia (goes quick, but be careful, too deep = stop breathing)
When watching for lar par have somone else call out when the dog is breathing out and in and you should see?
when brething in - arytenoids should pull apart and open the airway w/every inhalation
Dx of lar par is made based on?
Unilateral a problem?
What drugs may help?
Failure of arytenoids & vocal folds to abduct during inspration
Almost always both sides affected to see c/s
Doxapram - stim resp center to breathe - increase intrinsic laryngeal motion = aid DX
Surgery for lar par
Arytenoid lateralization - permanently pull one out of the way.
Anchor arytenoid in abducted position
=rima permantly dialted
Usu unilateral on L side (surgeons R handed, also shown in books)
What may be considered for lar par?
Muscle/nerve biopsy
EMG
Why aren't both arytenoids abducted?
predisposes animal to aspiration pneumonia
What about other surgical techniques?
Increased risk of complications including:
pneumonia, persistent/recurrent airway obstruction
None recommended anymore
For arytenoid lateralization
Dog in what position?
Neck in what position?
Incise where?
Dog: right lateral recumbancy
Neck: extended & supported on sand bag
Incise over larynx just below jugular vein bifurcation.
Wat muscle is incised for arytenoid lateralization?
What is retracted?
Then transect what? (2x)
Disarticulat what?
And finally?
Incise thyropharyngeous
Retrract wing of thyroid cartilage
Transect cricothryoid articulation
Transect CAD musccle
Disarticulate cricoarytenoid
Tie arytenoid (muscular process) to cricoid or thyroid.
Complications of artyenoic lateralizatoin?
Fragmentation of arytenoid
Failure to adequately open rima glottidis
Suture failure post op - place 2 non-absorb = prolene
Seroma or perilaryngeal edema (not usu imp)
Aspiration pneumonia (20-30% rest of lives)
Progressive polyneuropathy