Surgical Conditions of the Airway Flashcards
Presentation of brachycephalic obstructive airway disease?
> unstable obstructive crisis
- too much excercise
- stertor on inspriation and expiration
stable respiratory compromise
- snoring, excercise intolerance, noisy, potentially collapse
*NB: may not present until middle aged, not necessarily a problem from birth. May mouthbreathe to alleviate problem but this causes soft palate inflammation and oedema
Most common conditions of the nasal planum?
- trauma
- very haemorhagic
- pressure or suturing may be required - congenital deformities
- stenotic nares
- cleft/hare lip (1* palate cleft) occassionaly causes nasal discharge - neoplasia - often unilateral: ulceration or epistaxis
- SCC (erosive in cats, but responsive to wide loval excision and radiation tx)
- MCT (requires adjunctive chemo)
Emergency Tx of BCAD?
- oxygen
- cool IV fluids
- whole body cooling
- sedation
- emergency intubation/tracheostomy
Evaluation of stable brachycephalic dogs?
> rule out other causes of inadequate ventilation/tissue perfusion
- full PE (CV and pulmonary disease)
- serum chem and haemo
- thoracic and laryngeal rads (post obstruction pulmonary oedema possible)
- evaluation of upper airway (pharynx, larynx) under light plane of anaesthesia
Post-op care following laryngeal surgery?
- tracheostromy care routine
- remove trach after 24 hrs
- soft food 3-5d
- excercise restiction * check slides*
Tx of laryngeal collapse?
- orotracheal intubation
- emergency tracheostomy
- partial laryngectomy
- arytenoid lateralization
- permenant tracheostomy (probably most effective)
Clinical signs of laryngeal paralysis?
- excercise intolerance
- chronic cough
- ^ inspiratory noise (stridor) (man sawing wood. cf. sturtor or BAD)
- cyanosis or collapse
- dysphonia
- aspiration pneumonia
Aetiology of laryngeal paralysis?
- Congenital (rare) - bouvier des FLandes and huskys
- Acquired (KNown) - trauma, neoplasia (mediastinal, thyroid), 2* to polyneuropathy/polymyopathy (hypothyroidism, RLN problems etc.)
- acquired (idiopathic) - lab, retriever, setters
CLinical signs of laryngeal paralysis?
- hx chronic progressive exercise intolerance and cough
- dysphonia (change in bark)
- ^ respiratory noise (especially during inspiration STRIDOR, man sawing wood type sound)
- cyanosis and collapse following heat stress or excitement -> pyrexia
Primary and secondary pathology involved in brachycephalic airway obstruction syndrome? (BrachycephalicAirwayDisease)
1* - stenotic nares, long soft palate, ethmoturbinate bones may obstruct meatus
2* eversion of lateral laryngeal ventricles and laryngeal collapse
+ tracheal hypoplasia, redundant pharyngeal mucosa and scrolling of the epiglottis
POtential surgical tx of BAD?
- rhinoplasty
- staphylectomy
- resection of everted mucosa of lateral laryngeal ventricles
- temporary tracheostomy
- post-op keep quiet 7-10d
When is optimum age of tx for BAD?
Young to avoid 2* problems eg. tracheal stenosis
When is tube tracheostomy indicated?
- If endotracheal tubing not appropriate (this should always be first attempted procedure)
- If you need to wake animal up from GA
- surgery of oral cavity (routine, safe method of ventilating!)
- long term ventilation
Where is soft palate removed to commonly?
Level of caudal tonsilar crypt
Tx of tracheal hypoplasia?
None
- most dogs should be ok, some everely affected
WHat size tube should be used for tracheostomy?
SMaller than diameter of trachea to allow airflow around
- test upper airway function
- protect from tube blockage
How is the tracheostomy performed and how does wound heal?
- aseptic conditions, ventral midline incision, part paired sternothyrohyoid muscle bellies to expose trachea, place stay sutures either side of incision site, incise no more than 180* of trachea, insert tube
- suture wound but leave stay sutures long in case tube displaces so can pull trachea back to skin surface and reposition
- Left to heal by 2* intention
6 potential causes of nasal discharge?
- chronic hyperplastic rhinitis (prolonged inflam and ^ mucous secretion, more common in whippets, daschunds and cats)
- trauma
- dental diseasse (mucopurulent discharge, occasional epistaxis, unilateral, periapical lucency on radiographs and oral lesions)
- intranasal neoplasia (most malignant = solid carcinoma/adenocarcinoma, chondro/fibro/osteo sarcoma; benign polypoid rhinitis rare but if differentiated on histo prognosis good)
- Mycotic rhinitis (aspergillus, Penicillium)
- Foreign bodies (not as common as people suspect, sudden onset sneezing, serous discharge, mucopurulent discharge if chornic, may be seen on rhinoscopy)
Tx of chronic hyperplastic rhinitis?
- tx underlying factors
- rhinoitimy and turbinectomy if disease severe and intractable)
Tx and Potential complications associated with nasal cavity trauma?
- elevation of depressed bone fragments may be needed, use of wire sutures
- maxillary fx reduced to maintain dental occlusion
- acquired palatine clefts
- sequesrum formation -> discharging sinus or nasal discharge (rads for signs of sequestrum/osteomyelitis)
Tx of intranasal neoplasia?
- exploratory rhinotomy to confirm Dx, as Tx with radiation or palliative
- polyp removal -> good prog
Surgical treatement of mycotic rhinitis?
- if non-surgical tx fails
> surgical placement of irrigation tubes via sinusostomy to deliver Enilconazole therapy
Tx/diagnostics for potential nasal FB?
- radiolucent: may see on rhinoscopy
- flushing
- rhinotomy for confirmation/therapy
What 2 types of defects in the 2* palate are possible?
> congenital
- nasal return of milk, poor weight gain
- respiratory signs
- chronic nasal discharge potentially only sign in mild cases
aquired 2* to trauma
- aspiration pneumonia
- chonric nasal discharge and sneezing due to constant impaction of food into nasal cavity
Tx of defects in the 2* palate?
surgical repair when clinical signs exist - difficult and requires planning
What may occour 2* to BAD and do these affect outcome?
- tracheal stenosis (rarely affects outcome)
- larygneal collapse - very bad, creates severe problems, need tracheostomy tube
- post obstruction pulmonary oedema (will resolve spontaneously but may need to postpone surgery )
Investigation/diagnosis of obstructive crisis laryngeal paralysis?
- will be hyperthermic
- sedation (low dose ACP)
- oxygen
- cool IV fluids
- external body cooling
- rapid anaesthetic induction and orotracheal intubation
- tube tracheostomy permits complete patient evaluation prior to defintive treatment
Investigation/diagnosis of stable laryngeal paralysis?
- careful PE
- haematology and biochem for concurrent disease
- thoracic rads (pulmonary disease, medastinal masses)
- careful evaluation of laryngeal function under light plane of anaesthesia)
Tx laryngeal paralysis?
> left/unilateral arytenoid lateralisation
suture arytenoid to thyroid
laryngoplasty
suture arytenoid to cricoid to create prostheticcricoarytenoid dorsalis muscle
Post-op care following laryngeal paralysis surgery? (Arytenoid lateralisation or laryngoplasty)
- as for brachycephalic
- tracheostomy tube handy in case oedema blocks airway
- cough 2-3 weeks following procuedure normal
- aspiration pneumonia risk so monitor (^ risk if bilateral surgery performed)
- abnormal bark and noise on resp still possible, but aim to imprive QOL for old patient
Types of laryngeal neoplasia
- congenital rhabdomyosarcoma (oncocytoma)
- SCC
- adenocarcinoma
- chondrosarcoma
- fibrosarcoma
- lymphoma (Cat)
CLinical signs of laryngeal neoplasia
- dysphonia
- sonorous respiration
- excercise intolerance
- respiratory distess (may be indistinguishable from laryngeal paralysis)
Which condition may be confused for laryngeal neoplasia? How can they be distinguinshed?
- granulomatous laryngitis
- presents same way as laryngeal paralysis or laryngeal neoplasia
> biopsy!
What condition are small toy breeds predisposed to? What may exaccerbate this ? When do they commonly present?
Tracheal collapse
- poor cartilage development
- poor tracheal conformation
> abnormalities present from birth, present BIMODALLY as 1-3yo with 1* tracheal collapse OR 12-13yo multiple pathologies present, obese (more common)
> exacerbated by LRTI, heart disease, laryngeal dysfunction
Clinical features of tracheal collapse?
- vibrant insp and exp noise
- exacerbated with exctiement and excercise
- goose honking cough
- episodes of cyanosis and collapse possible
- DV flattening of trachea palapted
- gentle pressure can occlude the trachea
Investigation/diagnosics for tracheal collapse?
- plain rads mislead as dynamic obstruction, though CT good
- fluoroscpy
- endoscopy
- laryngoscopy to check larynx normal
How much of the trachea is commonly affected by tracheal collapse?
Whole trachea but cervical collapse most likeky to be seen
Tx of tracheal collapse?
- 1st line of tx = MEDICAL, treat underlying/concurrent disease, lose weight etc.
- surgical = salvage (conservative management failed or 1* tracheal collapse)
> Intralumenal - only good for old animals
- granulation tissue will form over stent and narrow airway
> extralumenal - good for young animals
- longer procedure but better tolerated in the long run
- cna be combined with arytenoid laterelisation if laryngeal function poor due to disease or post-op
Is tracheal trauma common?
Yes - bite wounds
> even if not penetrating can cause severe damage
> check for emphysema of neck -> pneumomediastinum and pneumothorax
- in cats, blunt chest trauma -> tracheal avulsion/rupture just cranial to carina (“intrathoracic tracheal avulsion”)
Are tracheal tumours common?
No very rare
Diagnosis/investigation of tracheal trauma?
- rads may show peritracheal, intermuscular and subcut emphysema
- positive contrast studies
- bronchoscopy (good for tracheal tears following intubation on dorsal trachea etc.
- exploratory surgery
Tx of tracheal trauma?
- strict cage rest and conservative care if stable
- surgical therapy if resp distressed
How are tracheobronchial FBs commonly removed?
- endoscopically or fluoroscopic guidance(rarely surgical)
- eg. cats inhaling small stones
Are 1* lung tumours common in dogs? What are the ost common types?
No
- majority are malignant adenocarcinoma
Clinical signs of lung tumour?
- cough and haemoptysis
- dyspnoea
- lethargy
- weight loss
- no clinical signs possible! may be found incidentally
Diagnosis and investigation of lung neoplasia?
- thoracic rads or CT
> exclude 1* tumour elsewhere in the body
Tx of 1* lung neoplasia?
- exploratory thoracotomy
- lung lobectomy
> rechecked every 3-6 months after surgery - thoracic rads to check recurrence
What is a spontaneous pneumothorax?
- closed pneumothorax
- no sign of trauma -> lung suspected as air source
Aetiology of spontaneous pneumothorax?
- rupture pulmonary bullae or blebs
- migrating inhaled plant material
- bacterial pneumonia
- chronic obstructive lung disease (emphysema and chonic bronchitis)
- asthma, TB, pulmonary neoplasia, parasites (filaroides)
Clinical signs of pneumothorax?
- tahcypnoea
- dyspneoa
- Excercise intolerance
- abscence of lung sounds on auscultation and thoracic resonance on percussion
- radiography/CT: careful in dyspnoeic animal, single DV ?
Tx of pneumothorax?
- stabilisationi with thoracocentesis or chest tube
- exploratory thoracotomy via median sternotomy and lobectomy
- prolonged pleural evacuation using chest drain
Which dogs are more prone to lung lobe torsion? Clinical signs?
- dogs with narrow, deep chest
- middle and right cranial lung lobes most commonly affected
- can be associated with chylothorax, trauma, thoracic surgery, neoplasia, chronic respiratory disease
> depression, innappetance, febrile
> dyspnoea and cough
> muffled lung sounds due to consolidated lung lobe or plerual effusion
> thoracocentesis, thoracic US, radiography and CT aid definitive dx (repeat imaging after drainage)
Tx of lung lobe torsion?
Lobectomy
What comes first: lung lobe torsion or pleural effusion?
no one knows!
- if chylothorax, that came first
Pathogenesis and pathophysiology of diaphragmatic rupture?
- blunt abdo trauma
- muscular (weakest bit) of diaphragm ruptures
- v input from diaphargm and v space for breathing
- thoracic effusions from trapped and strangulated anbdo organs (> signs of GI disease)
Diagnosis of diaphragmatic rupture?
- muffled heart sounds
- loss of lung sounds
- dull thoracic percussion
- empty abdo on palpation
> rads confirm (though if chronic pleural effusion may obscure so repeat rads after drainage) - do not stress patient*
Emergency tx of acute diaphragmatic rupture?
- thoracocentesis
- oxygen supplementation
- evaluate for multisyystem involvement
- no hurry to get to surgery!
>leave 24-48hrs unless stomach is dilating then immediate gastocentesis necessary
how can healing of chronic diaphragmatic rupture be treated?
debride wound edges
What is PPDH?
COngenital diaphragmatic disease
- Peritoneopericardial Diaphragmatic hernia
- failure of pleuroperitoneal folds to develop or intrauterine trauma
- may be associated with other congential abnormalities eg. intracardiac defects, abdo wall fusion, portosystemic shunt
What does PPDH appear similar to clinically?
Acquired diaphragmatic rupture
- rads to differentiate
Tx of PPDH?
- if patient is young repair surgically asap to v risk adhesions
- in older patient may be incidental finding so manage conservatively
How should the diaphragm be closed?
Dorsal -> ventral
What is EHH? Which breed is predisposed?
Eosophageal hiatal hernia (congenital)
- defect in formatio nof oesophageal hiatus
- hereditary in Chinese Sharpei
Pathophysiology of EHH?
- chronic reflux, regurgitation and vomiting
- chronic esophagitis, hypomotility and aspiration pneumonia
Diagnosis of EHH?
- history: ill thrift, regurge/V+
- PE likely to reflect 2* disease eg. pneumonia
- rads: air filled viscus dorsocaudal thorax but MAY be transient dynamic condition so fluoroscopy better
- alveolar pattern in cranioventral lung fields also indicative of aspiration pneumonia
Tx of esophageal hiatal hernia?
3 steps
- stomach returned to abdo, phrenoesophageal ligament gently dissected free
- defect closed and esophopexy sutures between ventrolateral oesophagus and diaphragmatic hiatus placed (2-3cm diameter, normal position)
- gastric fundupexy by tube gastromtomy or belt loop gastropexy
What are the most common tumours of the thoracic wall?
- osteosarcoma and chondrosarcoma from costochondral junction (malignant 1*s)
- hemangiosarcoma, fibrosarcoma, MCT and infiltrative lipomas of soft tissue chest wall can occour
Clinical signs of thoracic wall neoplasia? DIagnositics?
- palpable mass
- lameness due to pulmonary osteoarthropathy
> incisional biopsy
> Tx usually full thickness thoracic wall resection and reconstruction
