Upper Airway Surgery Flashcards
Procedure for guttural pouch mycosis?
Occlusion with balloon catheter (ACI, ACE, APM) Coil embolisation
Predisp factors of GP tympany
Arabian or paint horse
filly>colt
unilat>bilat
Cause of GP tympany
Plica salpingopharyngea one way valve
What age does GP tympany effect?
Few days/months up to yearling
GP tympany clinical signs
Not painful
Palpation: air-bag
Unilat may look like it’s bilat
Diagnosis of GP tympany
Clinical signs
Endoscopy: the pharynx collapses dors– but can decompress during endoscopy
Radio
Treatment of GP tympany
Foley catheter for 2-3 weeks
Transencoscopic laser surgery -fenestration of septum -removal of fold from the med plica salpingopharyngea
Clinical exam of the Guttural pouch
Visual: bloody dishcarge, xs bleeding
Palpation
Radio: fungal mycosis may be visible
How to solve arterial occlusion
Coil embolism
Balloon catheter occlusion
Cause of guttutal pouch mycosis?
Aspergillus sp
Symptoms of guttural pouch mycosis
Bloody discharge
epitaxis; maybe even liters, could be fatal
Functional disorders of the pharynx
- DDSP dorsal displacement of the SP- this often leads to number 2 pharyngeal collapse
- Pharyngeal collapse
- Abnormal head and neck position
Mostly dynamic
30% of horses have multiple disorders
The developmental abnormalitis of the pharynx
- Palatoschisis
- Choana atresia
Function of the pharynx
Conservative Treatment of DDSP
Tongue tie to fix larynx position
Cornell collar
Training for a year when they are young
If there is pharyngeal muscle weakness:
- NSAIDs
- Figure 8 noseband to keep the mouth closed
There is a 60-80% success rate
Treatment for iDDSP
I means intermittent and indicates pharyngeal muscle weakness
6-8 months regular exercise
DDSP surgical treatment
- Laryngeal tie forward (80%)
- Myectomy of m.sternothyroideus
- staphylectomy
- Scarring of SP with laser
- Epiglottis augmentation
Can also use combos of any of these treatments
prognosis: 50-60%
Difference between rostral and dors/lat pharyngeal collapse
Rostral
- Noise during EXP
Dors/lat
- Noise during INSP
- fatigue
Complication associated with pharyngeal collapse and DDSP
- Dysphagia– asp pneumonia
- Disturbances in wound healing e.g seroma formation
- Development of other dynamic disorders
if have iDDSP and do staphylectomy could be left with pDDSP
iDDSP and do tie forward- could lead to vocal cord collapse
What are the 2 main congenital Defects
Choana atresia
Palatoschisis
Choana atresia
Seldom a malformation
Persistent buccopharyngeal membrane
Usually unilat- can be asymptomatic at rest
Surgery when 1-2yrs
If bilateral- do tracheotomy, use laser-resection to do “stenting”
Palatoschisis
Usually malformation (therefore rarely congenital)
Can be HP or SP
Must be recognised in a newborn foal
Milk coming through nose
Cough
Asp pneumonia
Treatment of Palatoschisis
Euthanasia- if HP involved- prognosis is poor
Palato-plastica- with minimal tissue loss 50% prognosis
Pharyngeal cysts frequent locations
Subepiglottis
Pharyngeal wall
SP
Removal of Pharyngeal cysts
Surgical excision
Laser
Dynamic disorders of the larynx
- RLH- recurrent laryngeal hemiplagia
- Axial deviation of the aryepiglottic fold
- Collapse of the apex of the corniculate process
- Retroversion of the epiglottis
Permanent disorders of the Larynx
- Epiglottis entrapment
- Arytenoid chondritis
- Subepiglottial cys
- 4 BAD
Innervation of the intrinsic Pharyngeal muscles
Abductor
- Cricoarytenoideus dorsalis is innerv by the recurrent laryngeal nerves
- Cricothyroideus is innervated by the ext branch of the cranial laryngeal nerve
Adductor
- transverse arytenoid, lat criciarytenoid innerv by the Recurrent laryngeal nerve
Hemiplagia laryngis is also known as/etiology?
RLN recurrent laryngeal neuropathy
Pathogenesis of Hemiplagia laryngis/ RLN
Idiopathic!!
Progressive degen of dist fibres of the LEFT RLN- by axonopathy
Genetics- large horse breeds
From few months up to 10 years
Other causes of hemiplasia laryngis/ RLN
Accounts for around 6%
- Strangles
- Mycosis of guttural pouch
- Perivasc inj
- Periphlebitis
- Lead or organophosphate toxicosis
- Tumours of the neck or thorax
- CNS (EMND)
Clinical signs of hemiplagia larngis/ RLN
Insp noise during exercise
Poor performace
What can RLN lead to?
Paresis/ paralysis of RLN— These leads to:
- muscular atrophy
- Vocal cord collapse
- Arytenoid cartilage collapse
All during insp!
Diagnosis of RLN
- Palpation- Dorsal cricoarytenoid atrophy!
- US
- Endoscopy at rest: abduction after swallowing/closing the nares
- Slap test: the cervicolaryngeal reflex: contralat adduction
- DRE= dynamic endoscopy (treadmill)
Endoscopic findings of larynx
Abduction: corniculate processes (of aryt) move away from midline of the rima glottidis
Adduction: movement of corniculate towards midline of rima glottidis
Full abduction: corniculate lies horizontally (90 degrees to the midline of the rima glottidis)
Asymmetry: difference between L and R corn in relation to the rima glott
Asynchrony: movement of corn at different times- twitching, shivering, delayed biphasic movement
RLN grades at rest
Grade I
Arytenoid cart movements are synch and symm
Full arytenoid abduction maintained
RLN grade II at rest
cart movements asynch!
- transient ascynchrony
- flutter
- delayed
Asymmetry
- asymm of rima glott due to the affected arytenoid and vocal fold BUT there are times after swallowing or nasal occlusion when full symmetrical occlsuion is maintained
RLN grade III at rest
Cart movements asynch and asymm
Full arytenoid cart abduction cannot be maintained
- Full symm occlusion can be obtained but NOT maintained (after swallowing/closing of nares)
- Obvious arytenoid abductor deficit and arytenoid asymm- full abduction is never maintained
- Marked (not total) arytenoid deficit and asymmetry with little arytenoid movement, Full abduction never achieved
RLN grade IV at rest
Complete immobility of the arytenoid cart and vocal fold
Which side does the RLN grading system apply to mostly?
The left side
Grading of RLN by DRE/Treadmill
A
Full abduction of arytenoids during insp
Grading of RLN by DRE/Treadmill
B
Partial abduction of LEFT arytenoid cartilages (somewhere btw full ab and rest)
Grading of RLN by DRE/Treadmill
C
Abduction LESS than resting position!!
Collapse into the contralat half of the rimma glott druing INSP
Type of correlation between resting and dynamic endoscopy
WEAK
Treatment of hemiplagia laryngis
LP= laryngoplasty
Ventriculectomy or ventriculocordectomy
Arytenoidectomy (if LP is unsucessful)
Future? Pacemaker
Indications of Cordectomy/ ventriculocordectomy with Laser
If only the noise!! No effect on the performace
Should be done bilaterally with 3-4 weeks interface?
Standing
Transendoscopic
Post op of Cordectomy/ ventriculocordectomy
4 weeks: walks on hand then 2 weeks light exercise
At 6-8 weeks do a control exam via endoscope
Cordectomy/ ventriculocordectomy Complications
Laryngospasms
Edema/seroma in 7-30%
Wound infections: 0.5-6%
Cough will be present in 46% but this should redice to 14% after 6 months
LP not holding: 2-20%
Dysphagia <1%
Causes of poor performace following a LP or Cordectomy/ ventriculocordectomy
Collapse of arytenoid cartilages (failed tie back)
Vocal cord collapse on right side
Axial deviation of R aryepiglottic fold
- usually dynamic disorder, race or event horses
- can treat with transendoscopic laser excision
Clinical signs of axial deviation of R aryepiglottic fold
Poor performance that worsens with time (therefore often chronic?)
Older horses
Dont mix up with RLN
Ulceration
Kissing lesion
Acute:
- perichondral edema
- Fever, incr WBC’s
Treatment of axial deviation of R aryepiglottic fold
Acute:
- AB’s
- NSAIDS throat spray
Chronic
- Partial arytenoidectomy
Occurence and of Epiglottic entrapment
Persistent 97% (rarely dynamic)
Thinkened (97%)
Ulcerated (45%)
With epiglottic hypoplasia (31-36%)
Epiglottic entrapment Clinical signs
Insp noise
Race horses - poor performance
Coughing after drinking
Nasal discharge
Can be just an endoscopic finding !
Epiglottic entrapment: treatment
Diode laser
Occurrence of subepiglottic cysts
Young race horses
May be congenital in foals
subepiglottic cysts Clinical signs
Cough
Noises durign insp (asphyxia)
Dysphagia- asp pneumonia
Diagnosis of subepiglottic cysts
Endoscopy
Lat-lat X-rays
Palpation through the mouth
Treatment of subepiglottic cysts
Oral extraction
Laryngotomy- submucosal excision
Intrathecal inj of 4% formalin
Laser
What does 4 BAD stand for
4th brachial arch defect
What is the take home message
Resting endoscopy is not always the best to diagnose the cause of resp noise
Upper airway surgery requires exact anatomical knowledge and experience
Most frequent disorders: RLN and DDSP
R sided laryngeal paralysis is inidcative of 4 BAD
DDSP: noise during EXP
For cysts and entrapment minimal tissue loss is advantageous
