Soft tissue surgery Flashcards
what are Halsteds principles of surgery?
gentle tissue handling meticulous haemostasis preservation of blood supply strict asepsis minimal tension accurate tissue apposition obliteration of dead space
what is the least traumatic cutting instrument?
scalpel
what are the three different grips for holding a scalpel?
pencil grip
fingertip grip
palm grip
what’s the pencil grip used for?
short precise incisions
what is the disadvantage of the pencil grip?
not much contact of the blade with the surface so not suitable for making longer incisions
what is the fingertip grip used for?
long incisions (smooth cut as large contact between blade and surface)
what is a disadvantage of using the fingertip grip?
not as precise as the pencil
what is the palm grip used for?
cutting thick tissue (can apply force)
rarely used
what are the ways of cutting with a scalpel?
press cutting
slide cutting
what is press cutting?
(stab incision)
apply pressure to the tissue the same way in which you are cutting
what is slide cutting?
applying pressure to the tissue at 90° to the incision
what can be done to tissue to make slide cutting more efficient?
pull tissue apart with other hand so it is taut
what are straight tip scissors used for cutting?
tough tissue - connective tissue and fascia
what are curved tipped scissors used for cutting?
delicate fine tissue
what is the backhand thumb to third finger grip used for?
cutting towards you dominant hand (means you don’t have to awkwardly angle your arm)
what is the backhand thumb and index grip used for?
cutting backwards on the patient towards yourself
how do electrosurgical instruments work?
generating heat in the tissue by passing a high frequency electrical current through it
what are the two forms of electricosurgical instruments?
monopolar
bipolar
what are the differences between monopoly and bipolar electrosurgical instruments?
monopolar has a handpiece and ground plate
bipolar just has a handpiece
what can monopolar electrosurgical instruments be used for?
cutting and coagulation
what can bipolar electrosurgical instruments be used for?
just coagulation
what are the types of forceps used?
toothed forceps
dressing forceps
Alice tissue forceps
doyen forceps
what are toothed forceps used for?
tissue manipulation
what should Allis tissue forceps be used for?
only gripping things that won’t be left in the patients at the end of surgery such as tumours
what are doyen forceps used for?
occluding the lumen of bowels without crushing the tissue
what should be placed on tissue before putting retractors on? and why?
moist swabs
protect and keep tissue moist
what is lavage?
washing of a body cavity or tissue
what is lavage used for?
preserving tissues and keeping them moist
helps to remove bacteria
(don’t use antibacterials)
why is gentle tissue handling important?
reduce surgical trauma and improves outcome of surgery
why is meticulous haemostasis important?
haemorrhage obscures the surgical field, provides a medium for bacterial growth and can cause hypovolaemia
what is an example of curve tipped scissors?
Metzenbaum
what is an example of straight tipped scissors?
Mayo
what are the three forces a scissor depends on to cut?
closing force
shearing force
torque
what grip is used for routine scissor cutting?
wide-base tripod grip
what are the three ways of cutting with scissors?
scissor
push
blunt
what precautions must be taken when using electrosurgical instruments?
only used on anaesthetised patients
don’t use in the presence of flammable gas/liquid
ground plate must be in complete contact with the patient
don’t wrap power lead around towel clips etc
keep power as low as possible
what forceps are recommended for handling very delicate tissues?
DeBakey
what is a Balfour retractor used for?
abdominal wall retractions
working in the cranial abdomen (central blade lifts the diploid process)
what are finochietto rib extractors used for?
separate ribs for intercostal thoracotomy
divide halves of the sternum
what are the types of suction tip?
Frazier Ferguson
yankauer
poole
what is a frazier-ferguson suction tip used for?
fine work, removing haemorrhage during dissection
what is the yankauer suction tip good for?
removing large volumes of fluid
what is the poole suction tip good for?
removing fluid from body cavities
doesn’t block easily
what are some complication of improper tissue handling?
tissue ischaemia dead space formation (serum or abscess formation) wound contamination increased postoperative pain poorer cosmetic results
what factors is suture material selection based on?
tensile strength structure of suture chemical composition of suture local wound conditions wound healing rate
how should tensile strength of suture material be selected?
use the same strength as the tissue being sutured
what are the two structures of sutures?
monofilament
multifilament
describe a monofilament suture material
single strand of material that has little drag and can withstand contamination well
what are the disadvantages of monofilament sutures?
prone to damage when handling with instruments
have a high degree of memory which can make them harder to handle
describe multifilament suture material and their advantages
multiple strand of suture twisted together
they are easier to handle and more pliable, they also have better not security due to the higher surface friction
what are the disadvantages of multifilament suture material?
can labour bacteria and act as a wick which for bacteria to travel along
how are synthetic suture materials broken down?
hydrolysis (causes minimal tissue reaction)
how are natural suture material broken down?
enzymatic degredation (causing inflammation and tissue reaction)
what are the two shapes of needles?
straight
curved
what are straight needles used for?
for near the body surface or suturing skin
what are curved needles used for?
most sutures
what are the types of point profiles of needles?
round bodies
cutting needles
what are round bodies needles used for?
suturing easily penetrated tissues such as fat, viscera and muscle
what are cutting needles used for?
difficult to penetrate tissue such as skin
what are the three shaped of cutting needle?
conventional - cutting edge on concave side of needle
reverse - cutting edge on convex side of needle
taper-cut - mix of the two above
what are taper-cut needles used for?
suturing dense/tough fibrous tissue (eg. tendons)
CV procedures
what are the three needle holders?
Mayo-Hegar
Olsen-Hegar
Gillies
what is the difference between Mayo-Hegar and Olsen-Hegar needle holders?
Olsen-Heger has a scissor blade built into the holders
describe the Gillies needle holders
no ratchet
arms are different lengths
what are the three suture types pertaining to tissue alignment?
appositional
inverting
everting
what are the two main groups of suture pattern?
interrupted
continuous
define interrupted sutures
each suture has its own knot
they are easily placed and removed and allow adjustment of tension across a wound
they are also more failure tolerant than continuous patterns
name the types of interrupted sutures
simple
cruciate mattress
vertical mattress
horizontal mattress
name the types of continuous sutures
simple
continuous horizontal mattress
ford interlocking
what are the three aims of arresting haemorrhage?
do as rapid as possible
do as completely as possible
do with as little trauma as possible
what are ways of haemostasis?
pressure haemostats electrocautery ligature topical agents
how should pressure be applied to a site of haemorrhage?
with a moist swab for up to 5 minutes (time this)
don’t dab!
what type of haemorrhage is pressure used to apply haemostasis?
low pressure haemorrhage (bleeding from seal vessels - capillary ooze)
why should you always use the smallest haemostats possible?
create minimal tissue damage
what are the only vessels that haemostats should be used on?
blood vessels that will be sacrificed and don’t need to be patent after surgery
causes damage to lumen and closure of the vessel - permanently occludes the vessel
when putting two ligatures of large vessels for haemostasis, what type of ligature should be placed more distally (towards the cut end)?
transfixing
describe an encircling ligature
loop of suture passed around the vessel
describe a transfixing ligature
pass needle through wall of the vessel
tie a knot to hold it onto the vessel
pass suture around the vessel and tie
what vessels are transfixing ligaments used for? and why?
high pressure (arteries) they aren't pushed along the vessel by pressure - no risk of falling off
what are some examples of substances used as topical haemostasis agents?
collagen cellulose gelatin chitin mineral based
how do topical haemostatic agents work?
act as a scaffold for fibrin deposition and clot formation
some also activate the clotting
what are topical haemostatic agents mainly used for?
control of capillary haemorrhage (low pressure)
what is a downside of topical haemostatic agents?
can potentiate infection as they are a foreign material
what is a surgical infection?
infection that occurs at the surgical site within 30 days of the procedure (extended to a year if there is an implant placed)
what is nosocomial infection?
infections that are acquired in hospital (usually multiple antibiotic resistant)
what is sterilisation?
getting rid of all of the microorganisms present on an object
what is disinfection?
using a germicidal substance on a non-animate object
what is antisepsis?
using a germicidal substance on an animate object
what are prophylactic antibiotics?
antibiotics used to prevent infection occurring
what are therapeutic antibiotics?
antibiotics used to treat an infection that is already present
what does whether a wound becomes infected or not depend on?
number of bacteria present in the wound clipping the surgical site anaesthesia and surgical time use of propfol endocrinopathies (immunosuppressed) patients sex (males more likely)
what are the four categories of wound based on the number of bacteria likely to be present?
clean
clean-contaminated
contaminated
dirty
define a clean wound
elective surgical wounds not entering the respiratory, urogenital or GI tracts with no breaks in asepsis and primary closure
define a clean-contaminated wound
surgical wounds involving respiratory, urogenital or GI tracts without significant contamination or with a minor asepsis break
define a contaminated wound
fresh traumatic wound less than 4-6 hours old
surgical wounds involving respiratory, urogenital or GI tracts with significant contamination
surgery in the presence of inflammation
major breaks in asepsis
define a dirty wound
traumatic wounds greater than 4-6 hours old
traumatic wounds contaminated with foreign material
perforation of a hollow organ
surgery in the presence of abscessation
how does clipping of surgical sites effect wound infection?
clipping a long time before surgery increases risk - disturbance of skin leading to bacteria release
why does use of propofol increase the risk of wound infection?
has a lipid carrier in which bacteria can grow
what are some local wound environments and host defences that can effect whether a wound becomes infected?
tissue trauma foreign material ischaemia malnutrition chemotherapy systemic disease
what are the two categories of sites in which bacterial contamination can come from?
endogenous (inside the patient)
exogenous (outside the patient)
what are the main endogenous contamination sources?
skin
respiratory tract
GI tract
what are the main exogenous contamination sources?
room air
surgical team
instruments
drapes
why should waterproof drapes always be used?
if non-waterproof drapes get wet they can transfer bacteria from the underside of the drape
what are the two types of indicators that can be used to check the effectiveness of sterilisation?
biological
chemical
what is the advantage of advantage of biological indicators of sterilisation?
tell you if the autoclave has reach the correct temperature for the correct length of time to kill all the bacteria
(chemical just tell you if it reached the correct temperature)
when monitoring the wound post-operatively, what signs should be looked for that indicate infection?
heat pain redness swelling discharge
what types of wounds should prophylactic antibacterials be used in?
only clean wounds if the animals is immunosuppressed or surgery will last more than 90 minutes
in wounds that are going to be clean-contaminated or contaminated
(don’t use for dirt wounds - use therapeutic)
what are the three phases of normal wound healing?
lag/inflammatory
repair
remodelling
what happens during the repair phase of wound healing?
connective tissue repair - by fibrous and capillary growth
wound contraction
epithelialisation
what happens during the remodelling stage of wound healing?
increase in strength of the wound over many weeks
what are some local factors which will effect wound healing?
wound perfusion tissue viability wound fluid accumulation infection mechanical factors
what factors will reduce wound perfusion?
hypovolaemia
hypotension
vessel injury
pain
what factors will reduce tissue viability?
trauma dehydration osmotic injury envenomation chemical injury
what are mechanical factors which will reduce wound healing?
tension
motion
pressure
what are two systemic factors that may reduce wound healing?
immunosuppression (systemic disease and glucocorticoids)
neoplasia (radiotherapy and residual disease)
what ways can a wound be classified?
degree of contamination
aetiology
location
what are some classes of wounds based on aetiology?
abrasion avolsion surgical lacerations puncture
what is an avulsion wound?
part of the tissue is torn away from its underlying attachments (can separate blood supply)
what is the first thing to do when a patient is presented with a traumatic wound?
prevent further contamination (cover wound)
if you suspect a wound to be dirty/contaminated, what should be done before treating?
take a swab for culturing (appropriate antibiotic treatment)
when clipping what should be done to the actual wound?
fill with lubricating gel or sterile swabs to prevent contamination from hair
what should be used to lavage wounds?
sterile solution
can you tap water for very contaminated wounds
what can be done after the initial lavage of a wound?
debriding the wound
what are the ways of debriding wounds?
hydromechanical
surgical
how do does hydromechanical debriding work?
gels work to hydrate necrotic tissue and aiding it to undergo autolysis
how can tissue be assessed to determine if it needs debriding?
colour - is it purple/black
is a pulse present in any large vessels in the area
does it bleed
how can you make it easier for yourself to decide if tissue around a wound is necrotic or not?
leave the wound open for 24-48 hours for a clear line of demarkation to form between necrotic and living tissue
when are the only times wound debridement needs to be done immediately and the wound needs to be closed?
if it is so contaminated there is risk of sepsis
if the wound enters a body cavity
what should be done after debridement of a wound?
lavage
what are the 3 ways of managing a wound?
primary closure
delayed primary closure
secondary
what is primary closure of a wound?
immediate suture closure
what wounds is primary closure used on?
clean or clean-contaminated wounds
what is delayed primary closure of a wound?
closure of the wound 1-5 days after initial debridement before there is a chance of a granulation tissue bed to form within the wound
what should be done to a wound during delayed primary closure?
lavage and dress the wound every day
what type of wounds is delayed primary closure used for?
contaminated
wounds with a lot of tension or oedema in surrounding skin
what is secondary closure of a wound?
closure of a wound more than 5 days after the injury once a complete granulomatous tissue bed has formed
what must be done to close a wound for secondary closure?
incise a small amount of skin around the edge of the wound to remove the granulation tissue
what wounds would secondary closure be used for?
contaminated or dirty wounds after initial debridement and lavage has been completed
how are open wounds managed?
continued debridement - lavage, surgical, hydromechanical, dressing
protect wound using dressings
what are the three layers of dressings?
primary (contact), secondary, tertiary
what is the primary layer of a dressing?
makes contact with the wound
what does the type of non-adherent primary layer chosen depend on?
amount of exudate produced
if the wound is infected or not
what are semiocclusive/occlusive non adherent dressings indicated for?
wounds in the repair phase
what are calcium alginate dressings used for?
wounds with moderate/heavy exudate being produced as they are very absorbent
what are polyethylene/polyurethane film dressings used for? and why?
protection for intact feeding wounds as they are nonabsorbent and do not allow fluid pass, except water vapour
how long can polyethylene/polyurethane film dressings be left in place?
up to 2 weeks
what is an example of a hyperosmolar agent used for open wounds?
honey
why is honey a good hyperosmolar agent?
it is bactericidal due to high osmolarity, low pH and hydrogen peroxide production
why must honey used for wound be sterile hospital grade honey?
untreated honey can contain Clostridia
what are the two uses of maggots for wounds?
debriding and stimulate healing
how do maggots debride wounds?
enzymatic destruction of necrotic tissue
bacteria destroyed in their gut and by their secretions
what do maggots secretions stimulate in wounds to aid healing?
fibroblast activity
what are silver dressing used for?
wounds that have antibiotic resistant bacteria in them
how do silver dressings work?
release silver ions into the wound bed which are bactericidal against a wide range of pathogens
what is the function of the secondary layer of dressings?
absorb excess fluid from wound
secure primary layer
obliterate dead space
protect wound
what is the tertiary layer of the dressing for?
securing the rest of the dressing
keeps the dressing clean and dry
(ensure it isn’t too tight)
what can failure of good surgical technique or wound management result in?
delayed healing
prolonged discomfort
extra costs
what are the three main components of skin?
collagen fibres
elastic fibres
ground substance (mainly proteoglycans)
what are the layers of skin?
epidermis - stratum corneal, stratum grnaulosum, stratum spinosum, stratum basale
dermis - superficially papillary layer, deep reticular layer
what is the aim of wound healing?
restore normal physical form, structure and function
what are the types of cellular mediators involved in wound healing?
growth factors
cytokines
chemokines
what are growth factors and their function in wound healing?
proteins that bind to cell surface receptors resulting in activation of cellular proliferation and differentiation
what are cytokines and their function in wound healing?
small signalling proteins secreted by a variety of cells causing growth, differentiation and activation functions
what are the 3 main phases of wound healing?
inflammatory/lag phase
proliferative phase
remodelling phase
what % of the initial strength will a wound normally heal to?
80%
what are the functions of the inflammatory stage of wound healing?
haemostasis
protects against infection
substrate and cellular signals for the next step
what initially happens in the inflammatory stage after tissue disruption?
an initial transient vasoconstriction to occlude the injured vessels followed by vasodilation causing heat, redness and swelling
what is the function of fibrin in the inflammatory stage of wound healing?
create a seal and act as meshwork for other cells
what cells begin to aggregate during the inflammatory phase of wound healing?
platelets
what do platelets release in the inflammatory stage of wound healing?
chemoattractants
growth factors
proteases
what is the function of the substances released by platelets during the inflammatory phase of wound healing?
haemostasis
attracts other cells needed for wound healing
provide scaffold for migrating fibroblasts and epithelial cells
what characteristics of the inflammatory phase aid the removal of wound contaminate and damaged/dead tissue?
erythema and oedema of wound edges
what are the two key cells involved in the inflammatory stage of wound healing?
neutrophils
monocytes
what are the functions of neutrophils in the inflammatory phase of wound healing?
kill bacteria after being stimulated by various factors
what are the functions of monocytes in the inflammatory phase of wound healing?
mature to macrophages and decried wound
they are also essential for secretion of signalling molecules
what begins in the proliferative phase of wound healing?
angiogenesis
fibroplasia and granulation tissue formation
epithelialisation
contraction
what are the aims of the proliferative phase of wound healing?
permanent closure of the wound
replacement of lost tissue
what are some factors that influence the duration of the proliferative stage of wound healing?
wound size
location
age of individual
health of individual
what do fibroblasts synthesise during the proliferation phase of wound healing?
collagen
glycosaminoglycans
fibronectins
what do fibroblasts transform into during the proliferation phase of wound healing? and what do these do?
myofibroblasts
start to cause wound contraction
how is the proliferation phase clinically classified?
by the development of granulation tissue
what is the main substance involved in the remodelling/maturation stage of wound healing?
collagen
what are some local factors that will effect wound healing?
wound perfusion tissue viability wound fluid accumulation infection/foreign bodies mechanical factors (movement)
what are some systemic factors that will effect wound healing?
immunology oncology systemic conditions thermal injuries external agents excessive scarring
what are the two main classifications of wounds?
open
closed
what are some examples of open wounds?
surgical incision laceration abrasion degloving shearing puncture brun pressure sore
what are some examples of closed wounds?
contusion
haematoma
crush
hygroma
what are abrasions/erosions?
superficial loss of surface epithelium without exposure of underlying dermis and submucosa
how do abrasions/erosions primarily heal?
mitotic division (without inflammatory cells, capillaries, contractile elements)
what are ulcers?
complete loss of surface epithelium with exposure and damage to underlying tissue
what are contusions?
damage primarily to sub-epithelial tissues (bruise)
what is laceration?
combination of tissue damage and loss extending to any depth beneath the epithelium
what are the four types of burns?
thermal
chemical
electrical
radiation
what does the 1st, 2nd, 3rd, 4th degree burn describe?
the depth of the burn
what need to be done in the assessment of a wound?
initial history
initial first aid
initial wound assessment
what should be collected in a history ops a wound case?
full medical history (concurrent disease and treatment)
when injury occurred
how the injury happened
what should be done as initial first aid of a wound?
apply pressure if haemorrhaging
clinical exam to ensure no other injuries
check CV status (MM and HR)
sedate for safety
what can be used to lavage wounds?
chlorhexidine
providone iodine solution
(diluted)
what needs to be determined when initially assessing the wound?
location depth direction severity injury to other structures
what must you be aware of when assessing a wound, especially in horses?
tetanus contamination (fatal but can be prevented)
what three things are done to surgically manage a contaminated/infected wound?
lavage
debridement
wound closure?
what are the types of wound healing?
first intention (primary closure) second intention third intention (delayed primary closure)
what is first intention (primary closure) wound healing?
wound closed immediately and completely using strict ascetic technique
what conditions must be met for a wound to heal by first intention?
minimal bacterial contamination
revitalised tissue, foreign bodies, blood clots removed
no dead space/ischeamia/haematomas
why may a wound need to heal by second intention?
if it is infected or there is severe soft tissue damage
what is delayed primary closure?
treat wound as open initially to reduce bacteria and allow debridement then close it
what is done for aftercare of wounds?
antibiotics NSAIDs prevent self trauma rest animals if needed remove sutures
what is the trigone formed by?
the insertion of the urethra and ureters
define haematuria
presence of blood in the urine
when blood is seen at the end of urination, what part of the tract does this relate to?
upper urinary tract (kidney and ureters)
when blood is seen at the start of urination, what part of the tract does this relate to?
lower urinary tract (bladder and urethra)
what is polydipsia defined by?
water intake exceeding 100ml/kg/day
what is polyuria defined by?
urine output exceeding 50ml/kg/day
what is dysuria?
pain/difficulty to urinate
define oliguria
decrease in urine production below normal
define anuria
no urine production
what does a urinalysis consist of?
refractometer
dipstick
sediment examination
what are the three ways of collecting a urine sample?
free catch
catheterisation
cystocentesis
when catheterising a male cat what is it important to do?
gentle stretch the penis to extend and straighten the sigmoid flexure
what are the options of imaging for investigating patients with urinary tract issues?
radiography
contrast radiography
ultrasound
CT, MRI, cystoscopy
what are the roentgen signs?
size shape location number margination opacity
where are kidneys found on a radiograph?
retroperitoneal space
R - cranial pole of T13
L - L1 to L3
what are the kidneys compared to to gage their size on a radiograph?
the second lumbar vertebrae
what are the two types of contrast medium for contrast radiography?
positive and negative
how are negative contrast mediums seen on a radiography?
have less radiopacity than soft tissue so appear darker on radiographs
give some examples of negative contrast agents
room air
carbon dioxide
nitrous oxide
how are positive contrast mediums seen on a radiography?
are more radiopaque than soft tissue so appear lighter on a radiograph
give some examples of positive contrast agents
barium
iodine (main one for urinary studies)
what are the types of contrast radiograph that can be performed?
intravenous urography (excretory urography)
cystography
retrograde urethrography
what should be done before administering contrast mediums?
collect urine samples as some agents can inhibit bacterial growth
what are some indications for intravenous urography?
evaluation of kidneys/ureters indirect assessment of renal function investigation of uroabdomen investigation of urinary incontinence investigation of upper tract haematuria
what are contraindications of intravenous urography?
renal failure
dehydration
hypotension
hypovolaemia
why must patients be anaesthetised before administering contrast mediums?
some can cause anaphylaxis and vomiting so a secure airway is essential
what are the steps of performing intravenous urography?
anaesthetise
take plain abdominal radiograph
inject contrast medium intravenously
abdominal radiographs taken at regular intervals
what are the two techniques for intravenous urography?
bolus technique - low volume and high concentration, rapidly
infusion technique - high volume and low concentration, slowly
what is the bolus technique of intravenous urography used to assess?
kidneys
what is the infusion technique of intravenous urography used to assess?
ureters
what are the three phases of intravenous urography?
angiogram
nephrogram
pyelogram
what are the indications for cystography?
haematuria
dysuria
urine retention
incontinence
what can be assessed using cystography?
bladder location and integrity
bladder wall and mucosa
presence of calculi
what is the name of negative cystography using air?
pneumocystography
what are the steps of performing pneumocystography?
place a urinary catheter
insert room air/carbon dioxide/nitrous oxide
gently palpate bladder whilst injecting and then radiograph when distended
what are the contraindications of pneumocystography?
bladder rupture
mucosal trauma
haemorrhage
what are the steps of double contrast cystography?
place urinary catheter
empty bladder
inject air first
then inject positive contrast medium
what are the indications for retrograde urethrography?
haematuria dysuria lower urinary tract obstruction urethral disease prostatic disease penile disease
what are the steps of performing retrograde urethrography?
catheterise urethra and empty the bladder
perform a pneumocytogram
place the tip of the catheter at the distal urethra
inject the medium and take radiographs - need to take radiograph at the start of injection to check for urethral wall abnormalities
what are the indications for a retrograde vaginourethrogram?
ectopic ureters
vaginal disease
mass lesions within the pelvis/vagina
on ultrasound of the kidney what should be seen between the cortex and medulla?
clear demarcation
what can be assessed about a kidney on an ultrasound?
size
shape
internal architecture
renal perfusion
what can be assessed about the bladder on ultrasound?
wall thickness and layering
presence of mass lesions
lumen
what are the clinical signs of nasal disease?
sneezing snoring/increased respiratory noise nasal discharge epistaxis facila pain
what are the differential diagnoses for acute nasal disease?
nasal foreign body
viral URT infection
allergic/irritant rhinitis
tooth root abscess
what are the differential diagnoses for chronic nasal disease?
unresolved acute disease feline rhinotracheitis neoplasia fungal rhinitis lymphocytic/plasmacytic rhinitis
how can nasal disease be investigated on clinical examination?
inspection of the head palpation of the head retropulsion of the globe assessment of nasal airflow oral examination mandibular lymph node palpation
what should there not be when retropulsing the globe of the eye?
shouldn’t take much pressure, be discomfort or any asymmetry
how can nasal airflow be assessed?
putting fur/cloth infront of the nostrils
putting a mirror infront of the nostrils and see if it steams up
what should be done before taking a biopsy from the nose?
take a clotting profile - taking a biopsy can cause haemorrhage
how can nasal disease be investigated further after a clinical exam?
FNA of lymph nodes
nasal swabs - bacteriology and cytology
exploratory rhinotomy
what is the fungus that causes fungal rhinosinusitis in dogs?
Aspergillus fumigatus
what aged dogs is fungal rhinosinusitis normally seen in?
young/middle aged
rare in cats
what are the clinical signs of fungal rhinosinusitis?
nasal discharge (with/without epistaxis)
facial pain
ulceration/depigmentation of nasal planum
dullness/depression
how is fungal rhinosinusitis diagnosed?
history/clinical signs
serology (false negatives are common!!)
diagnostic imaging
histopathology (biopsy)
what is used to treat fungal rhinosinusitis?
topical antifungals
what are the two ways topical antifungals can be used to treat fungal rhinosinusitis?
trephination of frontal sinus and clotrimazole packing
noninvasive clotrimazole soaking
what is the rough outline of how clotrimazole soaking is done?
anaesthetise the patient in dorsal recumbency and place a Foley catheter around the back of the soft palate and inflate the bulb to block off the nasal pharynx. Place two more Foley catheters in each nostril and inflate, then inject clotrimazole until the nasal cavity is filled, clamp of each catheter and leave to soak for an hour
what dogs are nasal neoplasia usually seen in?
older medium/large breed dogs
what are the clinical signs of nasal neoplasias?
reduced airflow nasal discharge (with/without epistaxis) facial or palate swelling/distorsion exopthalmos neurological signs
how can nasal neoplasias be diagnosed?
history/clinical signs
diagnostic imaging
rhinoscopy and biopsy
how can nasal tumours be treated?
radiation therapy
chemotherapy
(surgery not normally an option due to access and haemorrhage)
what specific nasal neoplasia is chemotherapy used for?
nasal lymphoma
what is another name for non-infectious inflammatory rhinitis?
lymphocytic/plasmacytic rhinitis
what are the clinical signs of non-infectious inflammatory rhinitis?
usually non-specific
serous/mucopurulent discharge that is usually bilateral
sneezing/snorting
how is non-infectious inflammatory rhinitis diagnosed?
history/clinical signs
diagnostic imaging
rhinoscopy and biopsy
what is seen on diagnostic imaging of animals with non-infectious inflammatory rhinitis?
mild loss of turbinate detail
increased soft tissue density due to discharge
what are some treatment methods of lymphocytic/plasmacytic rhinitis?
environmental modification - cleaning, ventilating, humidifying
saline installation/nasal flushes
anti-inflammatories
antibacterials
mucolytics
allergen testing/elimination
(lots of options because nothing works very well)
what are the clinical signs of nasal foreign bodies?
sudden onset of signs
paroysmal sneezing
facial discomfort (pawing)
purulent nasal discharge
what can be done to diagnose nasal foreign bodies?
history/clinical signs
rhinoscopy
diagnostic imaging
exploratory rhinotomy
how are nasal foreign bodies treated?
nasal flushing
endoscopic retrieval
rostral retraction of soft palate and forceps retrieval
rhinotomy
how common is bacterial rhinitis in dogs/cats?
rare
what should be done to treat bacterial rhinitis?
treat the underlying cause
what are some other less common causes of nasal discharge?
cleft palate
ciliary dyskinesia
parasites
dysphagia and nasopahryngeal reflux
what are the two approaches to a rhinotomy?
dorsal or ventral
what would dorsal rhinotomy go through?
the maxilla and possibly more caudally through the frontal bone
what is the main risk of rhinotomy?
severe life threatening haemorrhage due to the area being highly vascular
breeds with short skulls can have brachycephalic obstructive syndrome, what are the consequences of this?
overlong soft palate stenotic nares tracheal/laryngeal hypoplasia pharyngeal collapse excessive turbinates
what secondary changes can occur due to brachycephalic obstructive syndrome?
everted laryngeal saccules
tonsillar enlargement/protrusion
laryngeal collapse
tracheal collapse
what are the clinical signs of braychephalic obstructive syndrome?
inspiratory stertor dyspnoea snoring/sleep apnoea exercise intolerance cyanosis fainting/collapse gagging/dysphagia regurgitation cough, pyrexia, dullness
define stertor
deep low pitch snoring type noise
how is brachycephalic obstructive syndrome diagnosed?
signalment/clinical signs
examination of airway - tonsils, soft palate, larynx
radiography - pharynx, neck, thorax
what is it important not to do when assessing the length of the soft palate?
don’t pull the tongue out as it will pull the larynx rostrally meaning length can be overestimated
what can be done to treat brachycephalic obstructive syndrome?
surgical modification of the airway
when should surgery of patients with brachycephalic obstructive syndrome be done?
as soon as possible but wait until animal is skeletally mature
why should we wait until a patient is skeletally mature to perform surgery on animals with brachycephalic obstructive syndrome?
proportions of head changes as the animal grows
tissue will be more robust when older
mouth is physically larger - easier access
what is the first part of the surgical treatment for brachycephalic obstructive syndrome?
widening the nares
what are the grades of laryngeal collapse?
stage 1, 2 and 3
what occurs on stage 1 of laryngeal collapse?
eversion of laryngeal saccules
what occurs on stage 2 of laryngeal collapse?
eversion of laryngeal saccules medial deviation of the cuneiform process of the arytenoids
what occurs on stage 3 of laryngeal collapse?
eversion of laryngeal saccules medial deviation of the cuneiform and corniculate process of the arytenoid cartilages
how is stage 1 laryngeal collapse treated?
laryngeal sacculectomy
how is stage 2 and 3 laryngeal collapse treated?
laryngeal sacculectomy with/without arytenoid caudolateralisation
what is done for very severe laryngeal collapse?
permanent tracheostomy
what is laryngeal paralysis?
the failure of dorsal cricoarytenoid muscle to abduct arytenoid cartilage on inspiration
what does laryngeal paralysis cause?
reduced glottis size and increased airway resistance
what are some causes of laryngeal collapse?
congenital dysfunction of recurrent laryngeal nerve
idiopathic dysfunction of recurrent laryngeal nerve (most cases)
metabolic neuropathy - hypothyroidism, myasthenia gravis
generalise myopathy
damage to recurrent laryngeal nerve - trauma /neoplasia
what breeds of dog are predisposed to acquired laryngeal paralysis?
golden retrievers
labradors
irish setters
afghan hounds
what are the clinical signs of laryngeal paralysis?
inspiratory stridor exercise intolerance fainting/collapse altered phonation cough/gagging during swallowing dysphagia
define stidor
high pitch whistling sound
what can exacerbate the clinical signs of laryngeal paralysis?
stress, excitement, heat
what can be done to diagnose laryngeal paralysis?
history/clinical signs laryngoscopy to assess laryngeal function thoracic/cervical radiographs blood tests electromyography/nerve and muscle biopsy edrophonium response test
what are the pitfalls of using laryngoscopy to assess laryngeal function for [patients with suspected laryngeal collapse?
if the patient is too deeply anaesthetised the larynx will become paralysed
can get paradoxical movement of larynx when animal inspired/expires
what is the main treatment of laryngeal paralysis?
surgery - left arytenoid lateralisation
why is only left arytenoid lateralisation done?
easier for right handed surgeon
unilateral gives adequate airway
bilateral increases the risk of postoperative aspiration pneumonia
describe the process of left arytenoid lateralisation
incision made ventral to the jugular
place suture between caudal border of the cricoid cartilage and muscular process of the arytenoid cartilage
what complication are associated with arytenoid lateralisation?
aspiration pneumonia
failure of tieback
seroma
development of other signs of neuropathy
what are patients that have had arytenoid lateralisation more prone to aspiration pneumonia?
can’t close glottis when swallowing so more prone to inhaling food
how can tracheal disease be investigated?
clinical exam - auscultation, palpation diagnostic imaging tracheobronchoscopy biopsy tracheal wash
what can cause tears in the trachea?
sharp or blunt trauma - bite wounds or ET tubes in cats
what are the clinical signs of tracheal tears?
can be asymptomatic or have subcutaneous emphysema/ pneumothorax/ pneumomediastinum
what can be done to treat tracheal tears?
cage rest if not severe
surgical repair after tracheostomy
where are tracheal avulsions usually found?
intrathoracically in cats
what can initially form in tracheal avulsion cases?
pseudotrachea - the animal will be asymptomatic
what is done to treat tracheal avulsion?
debridement and anastomosis - technically very difficult but with a good prognosis
what causes tracheal collapse?
laxity of tracheal muscles and chondromalacia of tracheal rings leading to dorsoventral collapse of the lumen
what is dynamic collapse of the trachea?
cervical trachea collapse during inspiration and the intrathoracic trachea collapses during expiration
what dogs is tracheal collapse most seen in?
middle aged miniature/toy breeds
what are the grades of tracheal collapse?
grade I, II, III, IV
describe a grade I tracheal collapse
laxity of dorsal tracheal membrane and a 25% reduction in tracheal lumen
describe a grade II tracheal collapse
laxity of dorsal tracheal membrane and widening of the cartilage leading to a 50% lumen reduction
describe a grade III tracheal collapse
further laxity of dorsal tracheal membrane and widening of the cartilage leading to a 75% lumen reduction
describe a grade IV tracheal collapse
w shaped tracheal cartilage rings so almost 100% occlusion of the trachea
what are the clinical signs of tracheal collapse?
goose honk cough waxing/waning dyspnoea exercise intolerance cyanosis flattening of cervical trachea on palpation
how can tracheal collapse be diagnosed?
signalment/history/clinical signs examination of upper airway fluoroscopy radiography - trachea, heart, lungs tracheoscopy bronchioalveolar lavage
what can be used to initially treat laryngeal collapse?
medical management often initially successful - corticosteroids, antitussives, bronchodilators, antibacterials weight loss avoid stress/excitement/heat harness instead of a collar treat concurrent disease
what surgical techniques can be used to treat laryngeal collapse?
stents
place extraluminal tracheal rings
what is tracheal stenosis?
abnormal narrowing of trachea due to granulation tissue formation after trauma
what can be done to treat tracheal stenosis?
resection and anastomosis
what can be done to treat tracheal neoplasias?
resection/anastomosis (if localised)
chemotherapy
radiotherapy
what are the two ways of accessing the trachea for surgery?
ventral midline cervical approach (in neck)
right 3rd-5th intercostal space thoracotomy (in thorax)
what type of suture is normally used for closing the trachea?
monofilament absorbable sutures (extraluminal knots)
why is a temporary tracheostomy usually performed?
to bypass potentially life threatening upper respiratory obstruction
how are temporary tracheostomy tubes maintained?
changed every 12 hours (or if blocked)
suction of air is required
moisturise airway every 1-4 hours
what are possible complications with temporary tracheostomy tubes?
tube obstruction premature removal gagging/coughing SC emphysema, pneumomediatinum, pneumothorax infection stenosis
what should be done when taking a tracheostomy tube out?
occlude it for 15-20 minutes to ensure patient can breath
how should the wound of a tracheostomy heal?
by secondary intention with appropriate care
where is permanent tracheostomy done?
at 4th to 6th tracheal ring
how should a permanent tracheostomy be maintained?
clean skin/stoma
trim hair
maintain body condition
no swimming
what is there maximum number of rings that can be removed in a tracheal resection?
5-6
which kidney is found more cranially?
right
which kidney is more mobile?
left
what are some possible developmental abnormalities of the kidneys?
(rare) renal agenesis renal dysplasia renal ectopia polycystic kidney disease
what is renal agenesis?
when a kidney and ureter aren’t present
what is renal dysplasia?
disorganised parenchyma of the kidney
what breeds are usually effected by polycystic kidney disease?
Persians and bullterriers
what are some indications of a renal biopsy?
renal mass (most common)
haematuria of upper urianry tract
renal corticoid disease
renal failure (may damage further by biopsying)
what tests should be carried out before doing a renal biopsy?
haematology biochemistry bacteriology diagnostic imaging coagulation profile
what are some contraindications for renal biopsy?
anaemia/coagulopathy oliguria/anuria severe azotaemia hypertension urinary obstruction hydronephrosis solitary kidney function
what a some complications with renal biopsy?
haematuria renal infarction infection haemorrhage renal fibrosis
what are the methods of renal biopsy?
FNA
tru-cut instrument
surgery
how can the kidney be approached for biopsy?
ultrasound guided percutaneous (blind) keyhole laprascopy ventral midline coeliotomy (most common)
when would a nephrotomy be done?
wedge biopsy
removal of nephroliths
what is nephrotomy?
cutting into the kidney
when taking a biopsy using FNA or trucut from the kidney, where is sampled?
cortex
how can the kidney be exposed after a ventral. midline coeliotomy?
drag the duodenum to the midline and this will expose the right kidney
drag the colon to the midline and this will expose the left kidney
how is the kidney cut to remove calculi?
bisectional - pole to pole
