Exam 2: Lecture 10 - Brachycephalic Syndrome Flashcards
Which breed of animals typically have a compressed face with poorly developed nares and a distorted nasopharynx
Brachycephalic breeds
Which head shape is the result of an inherited developmental defect in the bones of the base of the skul. These bones grow to a normal width but have reduced length. The soft tissues of the head are not proportionately reduced and often redundant
Brachycephalic breeds
What is the south Georgia definition
- flat nosers
- smushed faced dawgs
- Dawgs that chase parked cars
Typical affected brachycephalic dogs are?
- english bulldog
- french bulldog
- Pug
- boston terrier
- Shar pei
- cavalier king charles spaniel
- Lhasa apso
- Shih tau
- boxer
- pekingese
Which breed in an anesthesiologists nightmare and surgeons dream?
Brachycephalic syndrome
which syndrome refers to the combination of the surgically addressable conditions causing upper airway obstruction in brachiocephalic breeds
Brachycephalic syndrome
What are other names for Brachycephalic syndome
- Brachycephalic obstruction airway syndome
- Brachycephalic airway syndrome
What are the 3 major components of brachycephalic airway syndrome
- stenotic nares
- elongated soft palate
- everted laryngeal saccules
Brachycephalic airway syndrome is associated with?
- laryngeal collapse
- hypoplastic trachea
- nasopharynx turbinates
- tracheal collapse
- tonsil eversion
Other abnormalities that may cause or contribute to upper respiratory obstruction in brachycephalic dogs include?
- tracheal collapse
- obesity
- laryngeal paralysis
- masses obstructing the glottis, larynx, or trachea
- traumatic disruption of the airway
Stenotic Nares in congenital malformations of the nasal cartilages may result in?
- medial collapse
- Partial occulsion of the external nares
With Stenotic Nares, airflow into the nasal cavity is restricted and greater inspiratory effort is necessary, causing mild to severe _____
dyspnea
What does the following define?
Stenotic Nares
Is the left or right normal nares?
left
Is the left or right stenotic nares?
right
What structure in the nose needs to be removed to correct stenotic nares?
removal of the alar folds
What type of wedge shape, suture type, and blade number can be used for a subtotal removal of the alar fold to correct stenotic nares?
- Recession wedge (pie-shaped wedge)
- monofilament suture closure
- # 11 blade
What is the most common componet of brachycephalic syndrome?
Elongated soft palate
Define elongated soft palate in brachycephalic dogs
soft palate is pulled caudally during inspiration, obstructing the glottis
- increased inspiratory effort
- Causes more turbulent airflow
What happens to the laryngeal mucosa during elongated soft palate?
becomes inflamed and edematous, further narrowing the airway
What is this picture showing?
Elongated soft palate
Everted laryngeal saccules are reported in over half of dogs with which syndrome?
Brachycephalic syndrome
What is considered the first stage of laryngeal collapse
everted laryngeal saccules
T/F: It may be difficult to differentiate everted laryngeal saccules from the vocal folds. Everted saccules partially or completly obscure the vocal folds
true
T/F: Everted laryngeal saccules may be unilateral or bilateral
true
What is this image showing?
Everted laryngeal saccules
Define Hypoplastic trachea
congenital tracheal stenosis that affects the entire length of the trachea
- May be tolerated in the absence of concurrent respiratory or cardiovascular disease
Hypoplastic trachea can be associated with continuous respiratory distress, coughing and recurrent?
tracheitis
How can you diagnose Hypoplastic trachea?
radiographically by determining the tracheal to thoracic inlet diameter ratio
What is the definitive treatment for hypoplastic trachea?
No treatment is known
If an animal presents with the following history, what might you suspect?
- nosiy breathing, particularly on inspiration
- varying levels or respiratory distress
- frequent retching or gagging
- trouble swalloing caused by poduction of thick salivary secretions or normal occulsion of the airway during deglutition compromises ventilation
Brachycephalic syndrome
Concurrent gastrointestinal signs with Brachycephalic syndrome may include?
- dysphagia
- ptyalism
- regurgitation
- vomiting
The following history presents to your clinic. What is on your differental diagnosis list?
- exercise intolerance
- cyanosis
- restless sleeping (sleep-disordered breathing)
- collapse
Brachycephalic syndrome
What factors may make clinical signs of Brachycephalic syndrome worse?
excitment
stress
increased heat
increased humidity
Stertor / stridor result from upper or lower airway partial or complete obstruction?
upper airway
Are the sounds of stertor / stridor distinguishable upon where they orgionate in the respiratory cycle?
NO!!
they can be inspiratory or expiratory
How are the sounds of stertor / stridor distinct?
because of their pitch
Does the following define Stertor or Stridor?
- Low-pitched sound that is associated suggest that flaccid tissue is vibrating throughout the respiratory cycle
Stertor
Does the following define Stertor or Stridor?
- Sounds like a snore
Stertor
Does the following define Stertor or Stridor?
- High-pitched sound that result from rigid tissue vibrations
- typically associated with laryngeal or tracheal disease
Stridor
Does the following define Stertor or Stridor?
- laryngeal paralysis and tracheal collapse are two common presentations in companion animal practice
Stridor
On a PE, list some clinical signs that may be present with Brachycephalic syndrome
- pharyngeal and laryngeal auscultation revels prominent snoring (Stertor) and inspiratory stridor that obscures other respiratory sounds
- Inspiratory effort signs
- Mucous membrane signs
- Restless and anxious
- Hyperthermia
- Gastrointestinal tract distention
The following are signs of?
- Retraction of lip commissures
- open mouth breathing
- Constant panting
- Forelimb abduction
- exaggerated use of abdominal muscles
signs of increased respiratory effort
The following are signs of?
- Paradoxical movement of the thorax and abdomen
- Recruitment of accessory respiratory muscles
- Inwards collapse of the intercostal spaces and thoracic inlet
- Orthopenic posture - extended head and neck and reluctant to lie down
signs of increased inspiratory effort
What color mucous membranes can be seen in an animal with Brachycephalic syndrome
- normal with mild or moderate dyspnea
- pale or cyanotic with severe dyspnea
When an animal with Brachycephalic syndrome is restrained what can result in?
restless and anxious
How can Brachycephalic syndrome animals become hyperthermic?
results in ineffective cooling
How can animals with Brachycephalic syndrome get gastrointestinal tract distension
seondary to aerophagia associated with open-mouth breathing
Stenotic nares are identified on physical exam. Nares may be pulled ____ or may remain relatively stationary on inspiration (normally abduct(
- nares may be midly, miderately, or severly deviated medially during inspiration
Medially
How can you objectively assess airflow through the nares
holding a glass slife or piece of cotton near the nares
Why is it difficult to visualize the oropharynx and larynx on PE in Brachycephalic animals?
Because their tongues are thick, and restraint may accentuate respiratory distress
What diagnostic imaging may be needed for animals with Brachycephalic syndrome
- Thoracic radiographs
- Lateral cervical radiographs
- Advanced imaging may be warranted in some cases
Thoracic radiographs to detect Underlying cardiopulmonary abnormalities such as?
- cardiomegaly
- Pulomonary edema
- Pneumonia
Thoracic radiographs to detect underlying cardiopulmonary abnormalities may have other concurrent conditions such as?
- hypoplastic trachea
- hiatal hernia
- Heart base tumor
Lateral cervical radiographs evaluate?
- nasopharynx
- soft palate
- larynx
- entire length of the trachea
- nasopharyngeal, laryngeal, and tracheal masses may be identified
During a pharyngoscopy/ laryngoscopy owner permission to perform a soft palate resection is required, why?
General anesthesia required
Pharnygoscopy / laryngoscopy is used to evaluate the soft palate and functional assessment of the larynx. Initially what is these techniques done with?
rigid laryngoscope
Elongated soft palate overlies the _____ by a least a few millimeters, but often by more than 1 cm. Soft palate is often thickened and has a roughened, inflamed tip.
epiglottis
Ventrally or dorsally displacing the soft palate with a tongue depressor improves visulization of the arytenoid cartilages
dorsally
_____ are frequently inflamed and edematous. Tonsils may also be inflamed and everted from they crypts
Arytenoids
Everted laryngeal saccules appear as _______ protrusions of tissue that obscure the vocal folds
spherical
what are the 5 emergency medical management aspects of Brachycephalic syndrome
- airway
- oxygen
- sedation +/-
- Glucocorticoids
- Cooling
Long-term medical management of Brachycephalic syndrome include?
- weight reduction
- exercise restriction and elimination of preciptating causes
- glucocorticoids
- Supplemental oxygen and cooling for moderate to severe respiratory distress
Multiple procedures are usually required during surgical treatment of Brachycephalic syndrome, which include?
- stenotic nares resection
- resection of elongated soft palate
- resection of everted laryngeal saccules
T/F: Animals with upper respiratory obstruction are anesthetic and postoperative risks
true
______ ______ resection should be performed as soon as the animal is old enough to be safely anesthetized, and when the animals nasal tissue have matured enough to hold sutures (as early as 3-4 months of age)
stenotic nares
_____ of an elongated soft palate is best performed when the animal is young (4-24 months old), before laryngeal cartilages deform and collapse
resection
______ laryngeal saccules are often excised at the same time as soft palate correction is performed, although some surgeons will choose to leave them in young dogs with mild to moderate clinical signs
Everted
What is the correct patient positioning for correction of stenotic nares alone?
- sternal recumbency
- chin resting on a pad
- tape the head to the table
- planum nasale should be gently scrubbed
What is the correct positining in an animal with Stenotic nares
- sternal recumbency with the mouth fully open
- maxilla should be suspended
- Mandible secured ventrally with tape
- Chin should not be allowed to rest on the tabel or pads
- sponges should be placed around the endotracheal tube at the glottis to prevent fluids from entering the airway
- Oral cavity gently lavaged with dilute antiseptic soultions
- To prevent irritation and edema, the mucosal sufaces should not be scrubbed
How do you go about correcting a stenotic nares
- grasp the margin of the nares with brown-adison thumb forceps
- V-shaped incision around the forceps with a #11 scapel blade
- 1 to 3 mm deep into the alar fold
- first incision medially
- second incision laterally
- Remove the vertical wedge of tissue
How can you control hemorrage when correcting stenotic nares?
control hemorrhage with digital pressure and by reapposing the cut edges
Align the ventral margins when correcting a stenotic nares and the mucocutaneous junction, and place 3 to 4 ____ ____ sutures using synthetic rapidly absorbable material to reappose the tissue
simple interrupted
what is this imagine showing?
Recession wedge correcting a stenotic nares
- making a triangular incision with a #11 blade
When correcting stenotic nares and making the triangular excision, how do you place sutures when closing?
from medial to lateral when closing
What is a staphylectomy
elongated soft palate resection
What instruments / techniques can be used during an elongated soft palate resection
may be done with scissors, carbon dioxide laser, electrosurgery, or a bipolar sealing device
Using electrosurgery during Staphylectomy may cause?
increase postoperative swelling
Using electrosurgery and lasers during Staphylectomy may cause?
ignite oxygen if proper safety precautions are not taken
Using laser resection during Staphylectomy may cause?
- significantly shorter surgical time that scissors
- No difference in outcome has been noted between the two methods
How does hemorrhage look during Staphylectomy
generally mild to moderate
- controlled with gentle pressure
The caudal margin or the soft palate should be shortened during Staphylectomy so that it?
- contracts the tip of the epiglottis
- COntracts the roof of the nasopharynx when pushed dorsally
T/F: resection during Staphylectomy of too little soft palate does not optimally relieve respiratory distress
true
Resection of too much soft palate during a Staphylectomy may result in?
- nasal regurgitation
- rhinitis
- sinusitis
An elongated soft palate overlies the eipglottis by the least few millimeters, but often by more than ____ cm
1 cm
What are the landmarks for (elongated soft palate resection) Staphylectomy proposed resection?
- tip of the epiglottis
- caudal margin of the midpoint of the tonsils
Hand the soft palate ____ and as little as possible during (elongated soft palate resection) Staphylectomy
gently
Grasp the midline of the soft palate with thumb forceps durnig (elongated soft palate resection) Staphylectomy and place what type of sutures
stay sutures
- place additional stay sutures at the proposed site of resection on the right and left borders of the palate
- The place hemostats on the stay sutures
Trascent across ____ to half the width of the soft palate with curved matzenbaum scissors
- begin a simple continious suture pattern at the border of the palate
(4-0 absorbable monofilament suture)
one third to half the width of the soft palate
T/F: Appose the oropharyngeal and nasopharyngeal mucosa during (elongated soft palate resection) Staphylectomy
true
Why would you want to use longer instruments during (elongated soft palate resection) Staphylectomy
assist reaching the sugical site in the back of the oropharynx region
What type of instruments are on the left side?
Metzenbaum scissors
What type of instruments are one the right side?
DeBakey Forceps
T/F: during a (elongated soft palate resection) Staphylectomy avoid atruamatic techniques, specially avoiding clamps and cautery
true
Possible complications from resection of everted laryngeal saccules are?
- Laryngeal swelling
- Laryngeal webbing
- regrowth
T/F: Recommendations that saccules should NOT be removed if they cause an airway obstruction
FALSE!!
removed only when believed to contribute significantly to airway obstruction
The challenges of resection of everted laryngeal saccules are?
- Good visualization of the larynx and epiglottis
- Minimal handling of tissues - excessive manipulation can cause local obstructive edema postoperatively
- Use extreme care if laser or electrosurgical excision is used, to prevent trauma to surrounding tisues and igniting of flammable gases
What do you want to REMEBER about post operative care and assessment of resection of everted laryngeal saccules?
patients require constant monitoring
Post opertive care and assessment of resection of everted laryngeal saccules animals / cases are?
- patients require constant monitoring
- closely observe for respirtaory distress until completely awake
- recover the animal in a quite environment while oxygen saturation is being monitored with pulse oximetry
- Optimally, the animal should be placed in sternal recumbency with the front limbs extended out and fowards
- Head and neck should be placed in extension with the tongue pulled fowards
Before or after extubation, induction drugs, laryngoscope, endotracheal tube, and O2
before extubation
- needs to be immediately available
- reintubation needs to be considered if O2 saturation does not stay in the 90’s
- O2 may be administered by nasal insufflation
mild hemorrage may lead to?
- coughing
- gagging
- hematesmesis
Post operative swelling and edema may cause?
severe laryngeal obstruction
When would reintubation or placement of tracheostomy tube be necessary?
if respiratory obstruction or severe distress occurs
Which meds may be administered postoperatively is swelling is severe and if respiratory obstruction persists
Glucocorticoids
The following are what type of instructions for the owner/Dr.
- hospital observation is recommended for 24 to 72 hours
- IV fluids should be maintained until oral intake resumes
- Excessive mucosal swelling may cause asphyxiation
- Postoperative coughing anf gagging are common
- Water, ice water or ice chips may be offered when the animal is fully recovered from anesthesia
- Food should be withheld for 12 to 24 hours
- Offering food soon after surgery may traumatize swollen tisses, causing swelling, airway obstruction, aspiration, or all of these
What is the prognosis after surgery?
- most will be improved, but not normal
(alleviate signs of resp. distress and improve quality of life in most dogs) - dependent on age of the animal at time of surgery and how severly the dog is affected
- recent studies describe a good to excellent long term outcome in the majority of dogs
- Major complications including death or euthanasia occurs approximately 5%
- most beneficial result of multilevel surgery for airway obstruction in brachycephalic dogs is the marked reduction in life threatining events of choking and collapse
Which breed of animals have been found to have a worse response to surgery when compared with other breeds combines and are more likely to develop aspiration pneumonia postoperatively
english bulldogs
If advanced largngeal collapse has occured, the prognosis is considered?
poor, unless additional surgery is considered
What is defined as form of upper airway obstruction caused by loss of cartilage rigidity that allows medial deviation of the laryngeal cartilages = arytenoid collapse
Laryngeal collapse
- different from laryngeal paralysis
Which stage of laryngeal collapse is described?
- Commonly referred to as laryngeal saccule eversion
1
Which stage of laryngeal collapse is described?
- medial deviation of the cuneiform cartilage and aryepiglotic fold
= aryepiglottic collapse
stage 2
Which stage of laryngeal collapse is described?
- Medial deviation of the corniculate process of the arytenoid cartilages
= corniculate collapse
stage 3
How many stages are in laryngeal collapse?
3
Which stage of laryngeal collapse is described?
- advanced stages or laryngeal collapse
2 and 3
Management of laryngeal collapse include?
- weight loss
- avoid overheating
- Sedation + steroids PRN.
- permanent tracheostomy
