Head and Neck Surgery Flashcards
What components of brachy airway syndrome?
-> Primary lesions
- elongated SP
- Stenotic nares
-> Secondary lesions
- Laryngeal collapse
- Eversion and inflammation of tonsils
also: macroglossia, hypoplastic trachea
what associated Gi disease ?
- Many BC dogs have episodes of regurgitation or
vomiting - Severity of respiratory and GI signs correlate
- Oesophagitis in 36% cases
- Gastritis present in 95% cases
- Regurgitations can in turn cause further upper airway
inflammation
how can we manage GI dx alongside BC surgery?
Consider treating with metoclopramide or cisapride
and omeprazole for a few days before and for 4 weeks after surgery
Explain the pathology behind brachy airway syndrome?
Describe stenotic nares?
- Congenital malformations of nasal cartilages
- Early treatment may prevent secondary changes
3-6 months old
Describe a vertical wedge rhinoplasty
- # 11 blade. GO DEEP
- 4-0 Monocryl cutting needle
- Cruciate pattern
Why might it be better to do a punch resection aplasty?
potential adv that it may be easier to make both sides symmetrical here
What function of the soft palate?
The caudal soft palate is elevated dorsally by the paired levator veli palatine muscles to close the intrapharyngeal opening
why does soft palate function matter in surgical setting?
If you cut it too short there will be reflux of food in the
nose and rhinitis
how can we assess the soft palate
1-Caudal tip of palate should just touch the tip of epiglottis
Without pulling on the tongue
2- Caudal tip of palate should be at caudal edge of tonsils
Elongated Soft Palate tx?
- Well inflated cuff & pack gaues
- Nice to have long needle horses
- Monofilament absorbable
- Curved cut to match the contour of epiglottis
- I like the palate to completely clear the epiglottis
Other reported options ?
- Folding palatoplasty
- CO2 Laser
- Radiofrequency unit (Ligasure)
- Electrocautery
Everted saccules?
- Grade 1 laryngeal collapse
- Normal fold of mucosa
- Inside out trouser pocket
- Negative pressure
How do we grade laryngeal collapse?
- Grade 1: everted saccules
- Grade 2 = 1 + collapse of cuneiform processes of arytenoids
- Grade 3: 1+2+ collapse of corniculate processes of arytenoids
Tx for laryngeal collapse?
- Treat other components of brachycephalic
syndrome - Tie-back surgery
- Permanent tracheostomy
What breeds predisposed to Idiopathic acquired form of laryngeal paralysis?
Older large breeds
- Lab retreiver
- St bernard
- Irish setter
Presentation with laryngeal paralysis?
Inspiratory stridor
Voice change
Coughing/gagging
Hot weather?
Aspiration pneumonia
Diagnostics of laryngeal paralysis?
- Good history
- CBC, panel, Thyroid evaluation
- Thoracic and laryngeal radiographs
- Laryngoscopy (endoscope or laryngoscope) under a light plane of anesthesia
- Arytenoids watched for ability to ABduct
- EMG’s other neuromuscular
Immediate therapy for laryngeal paralysis?
- Cooling
- Oxygen
- Sedation
- Corticosteroids
+/- intubation
+/- iv fluids
Tx options for laryngeal paralysis?
- Arytenoid lateraliation ‘tieback’
- Partial laryngectomy with unilateral vocal fold resection
- Bilateralvocal fold resection
- Permanent tracheostomy
Indications for temporary tracheostomy?
- Upper Airway Obstruction: Trauma, Neoplasia, anaphylaxis
- Surgical procedure on upper airway/ oral cavity
- Need for mechanical ventilation
Why is temporary tracheotomy not ideal?
- If a permanent tracheostomy is likely needed in the future
- If a laryngeal tie-back is to be performed
Tracheostomy tubes?
- No more than 50% of tracheal diameter
- ½ the size of what you would use as endotracheal tube
Temporary tracheostomy: anaesthesia?
- GA
- Use anticholinergic
- Intubate with endoT if poss
- Routine prep of skin
Steps? of temp tracheostomy?
- Incise the memebrane b/w rings 3 and 4 no more than 50% of tracheal circumference
- Tie loops for each suture around the cranial and caudal ring and keep ends long and label them
- PPull endotracheal tube and replace with tracheostomy tube
Mucus production?
- Foreign body reaction
- Dry air is irritating
- Aftercare is very important to prevent occlusion of the tube.
Post op care fo temp tracheostomy?
Sterile suctioning every 15 minutes-2 hours
Preoxygenate and instill 1 ml of sterile saline in trachea prior to suctioning.
Cleaning of the tube in sterile cup with sterile saline q 4-8 hrs
What to always do to avoid hypoxia?
preoxygenate before suctioning the trachea
What complications post-op?
- Bradycardia
- Tube dislogement: pull sutures and replace
- Tube occlusion
How can I remove the tube?
- Can test if upper airway problem has resolved by occluding the tube
- Non adherent bandage and will granulate and heal in 7 days
- Monitor for 24 hours in hospital after tube
removal
Permanent trach tube - indications?
- Severe laryngeal collapse
- Neoplasia
- Severe laryngeal trauma
Possible contra-indications for permanent trach?
- 50% mortality in CATs first few weeks, likely due to mucus plugs
- High rate stenosis
How to do a permanent trach?
- Window 3-4 rings and 1/3rd circumference of the trach
- Attempt to preserve the mucosa
- Suture the skin to the trachea around the stoma
- Mattress sutures
- Prevents skin folds from occluding the stoma
- Resect excessive skin folds
Aftercare?
- In hospital 4-5 days
- Suction trachea as needed
- First 4 weeks
- Use Q tips to clean stoma at home as needed
- Can use baby nose aspirator
- Wear bandana
- Clip hair
- No swimming!!
Complications of permanent trach?
- Aspiration pneumonia
- Stenosis of the tracheostoma
- Tracheal collapse
- Acute obstruction of trachea suspected and death in 5/19 cases
- Initially with secretions or skin folds
- Later on foreign material
