Upper airways (E1)

Question 1

What is the purpose of inserting silicon tubes that protrude from the nares when performing nasal surgery?

Answer 1

To maintain the airway/To keep the airways open

Question 2

What condition is nasal planum resection most commonly associated with?

Answer 2

Neoplasia (SCC)

Question 3

Accurate apposition of nasal _____ and ____ reduces the risk of post- nasal planum resection stenosis in dogs,

Answer 3

Mucosa

Skin

Question 4

T/F: The first line treatment for nasal fibrosarcoma is chemo and radiation, if that does not work surgery should be considered.

Answer 4

False, resection is the primary method of treatment since FSA do not respond well to chemo or radiation.

Question 5

What is the best modality to assess oropharyngeal and nasal pathology, such as polyps?

Answer 5

CT

Question 6

__________ sutures work well in cats to decrease the size of the wound, allowing the remaining defect from a nasal planum resection to heal by second intention.

Answer 6

Purse-sting

Question 7

What anatomic structure must you take care to avoid when performing a blind nasal biopsy?

Answer 7

Cribiform plate (no touchies)

Question 8

Which arteries do you risk damaging when performing nasal surgery?

Answer 8

Dorsal, lateral and major palatine arteries

Question 9

What are some primary components of brachycephalic airway syndrome

Answer 9

Elongated soft palate (most common)

Stenotic nares (also common)

Shortened, flattened nasal cavity (nasopharyngeal turbinates)

Hypoplastic trachea

Question 10

What inspiratory noise is associated with an elongated soft palate?

Answer 10

Stertor

Question 11

T/F: Placement of a stent is the primary treatment for hypoplastic trachea.

Answer 11

False, there is no treatment.

Question 12

Which drugs should you avoid when performing an upper airway exam, because they affect laryngeal function? What is usually used?

Answer 12

Ketamine

Diazepam

Large doses of pure mu agonists

Use: Propofol +/- Bup or Torb, Doxapram if they get too deep

Question 13

What surgery is necessary for stage 1 tracheal collapse? Stage 2? Stage 3?

Answer 13

1: Excision of everted laryngeal saccules
2: Above + vocal fold excision and partial arytenoidectomy
3: Permanent tracheostomy

Question 14

At the beginning of an upper airway examination you notice small pear-shaped masses just in front of the vocal folds. What are these?

Answer 14

Everted laryngeal saccules

Question 15

What landmarks are used to determine the level of excision when resecting a soft palate?

Answer 15

The caudal border of the soft palate (should slightly cover the tip of the epiglottis on the midline)

Caudoventral border of the tonsillar crypt

Question 16

Why are wet sponges used around structures that area not meant to be cut by a CO2 laser?

Answer 16

To protect them by absorbing the laser beam

Question 17

T/F: Nasal stenosis is more common in cats than dogs post-op.

Answer 17

False, dogs.

Question 18

T/F: Rhinoscopy and nasophyngoscopy should be performed after imaging.

Answer 18

True

Question 19

Progressively worsening inspiratory dyspnea which is exacerbated by exercise is the most common clinical sign for _____.

Answer 19

BAS

Question 20

When performing nasal surgery, a ______ approach gives you access to the nasal cavity and sinuses, while a _____ approach gives you access to the choanae.

Answer 20

Dorsal

Ventral (also gives access to ventral nasal cavity)

Question 21

Which technique is the easiest but also most traumatic for soft palate resection? Broadly, what type of suture and what suturing pattern would you use?

Answer 21

Clamp/crush technique

Fine absorbable monofilament suture (e.g. 4.0-6.0 Monocryl or Biosyn)

Continuous pattern, from edge to midpoint on each side

(Also, remember you (clamp,) cut, and suture one side and then (clamp,) cut, and suture the other side)

Question 22

T/F: Tracheal collapse and everted laryngeal saccules are secondary or acquired components of brachycephalic airway syndrome.

Answer 22

True

Question 23

If a laser is not available, what technique for resecting a soft palate is recommended?

Answer 23

Free-hand “cut and sew”

Question 24

What complications accompany an overshortening the palate in a palatectomy?

Answer 24

Nasal reflux

Aspiration

Question 25

T/F: An upper airway exam should be performed under deep anesthesia to prevent swallowing.

Answer 25

False

Question 26

What technique for a palatoplasty would you use if you wish to both shorten and thin the palate?

Answer 26

Folded Flap

Question 27

What are acute complications following a palatectomy?

Answer 27

Hemorrhage Inflammation

Question 28

What do you do if you discover that while performing a palatectomy you undershortened the palate?

Answer 28

Redo the surgery

Question 29

What diagnostics, aside from an upper airway exam, are warranted when working up a case of BAS?

Answer 29

Thoracic radiographs Blood work (especially if in distress) +/-: Lateral cervical rads, abdominal rads/US

Question 30

What therapies are commonly administered pre-op to soft palate resections and everted saccule excision?

Answer 30

**Dexamethasone/ corticosteroids (ALWAYS)** GI protectants and promotility agents Anti-emetics Pre-oxygenation

Question 31

What is considered to be the first step in the pathogenesis of laryngeal collapse?

Answer 31

Eversion of laryngeal saccules

Question 32

What occurs as laryngeal paralysis progresses from stage 1 to stage 2? (Hint-involves cuneiform processes)

Answer 32

Cuneiform processes rotate medially (which may cause minimal to no abduction of the arytenoids when viewed during laryngoscopy)

Question 33

What 2 things should you consider when choosing which technique to use to correct stenotic nares?

Answer 33

Severity of collapse Static vs Dynamic collapse

Question 34

What analgesic drug is commonly used after a surgery to repair stenotic nares?

Answer 34

Buprenorphine

Question 35

You have a patient whose laryngeal cartilages are collapsing medially but some glottic lumen remains. What stage of laryngeal collapse are they in? What surgeries are indicated?

Answer 35

Stage 2 Partial arytenoidectomy and vocal fold resection

Question 36

T/F: A unilateral partial arytenoidectomy is greatly preferred to a bilateral to reduce the risk of creating laryngeal incompetence leading to aspiration pneumonia.

Answer 36

True

Question 37

Why is arytenoid lateralization surgery not helpful In the treatment of laryngeal collapse?

Answer 37

Because it may make the collapse worse if the cartilages do not have normal rigidity

Question 38

What approach do you take when performing a partial arytenoidectomy and vocal fold resection? What is the most common complication and how is it prevented?

Answer 38

Oral Post-op stricture ("webbing") **Keep the ventral commissure of the vocal fold intact** and do not cut to the dorsal or ventral extents of the corniculate processes and vocal folds.

Question 39

T/F: When performing a permanent tracheostomy, the stoma should be made smaller than you would think necessary because the hole will stretch out as it heals.

Answer 39

False, must be made LARGER because a 40-50% reduction of the stoma is typical during healing

Question 40

Your patient develops fever post-operatively after laryngeal surgery. What complication do you fear has occurred?

Answer 40

Aspiration pneumonia

Question 41

What congenital condition for which clinical signs usually begin around 4-6 months of age is frequently reported in Bouvier des Flanders, Siberian huskies, bull terriers, Leonbergers, Dalmatians and Rottweilers? Progressive deterioration can occur at a rapid rate, especially in Rottweilers.

Answer 41

Laryngeal paralysis

Question 42

At which stage of laryngeal collapse may the corniculate and cuneiform processes overlap? What surgery is indicated?

Answer 42

Stage 3 Permanent tracheostomy

Question 43

Which muscle is responsible for laryngeal abduction?

Answer 43

Crycoarytenoidesous dorsalis

Question 44

What acquired condition occurring most frequently in older, medium to giant breeds of dog such as Labrador retrievers, has an insidious onset with intermittent episodes of severe respiratory distress?

Answer 44

Acquired laryngeal paralysis

Question 45

What are the openings between the nasal cavity and the nasopharynx called?

Answer 45

Choanae

Question 46

Laryngeal paralysis results in an inability to properly abduct the laryngeal cartilages during \_\_\_\_\_\_\_.

Answer 46

Inspiration

Question 47

Why is it important to do a thorough neuro exam, especially in young patients, before undertaking surgical correction of laryngeal paralysis?

Answer 47

Laryngeal paralysis might be the earliest sign of generalized neuromuscular disorders

Question 48

What 3 methods can you use to stimulate deeper inspiration while evaluating the larynx?

Answer 48

Tracheal palpation Laryngeal stimulation **Doxapram administration (least likely to cause coughing, so preferred)**

Question 49

What type of laryngeal paralysis is most common in small animal patients?

Answer 49

Idiopathic acquired bilateral

Question 50

What is the purpose of arytenoid lateralization for treatment of laryngeal paralysis? What structures are sutured together in this procedure? Is this done uni- or bilaterally?

Answer 50

To **open the rima glottidis** enough (usually 2x size of resting) to **relieve the airway obstruction** but not so wide as to make the larynx incompetent during swallowing Suture (2 interrupted non-absorbable sutures) the m**uscular process of the ARYTENOID cartilage in abduction to the CRICOID cartilage** UNILATERALLY

Question 51

What cases of tracheal trauma would necessitate surgical intervention?

Answer 51

Severe, visible rupture/damage caused by ETT If dyspnea persists or worsens with medical management If pnemothorax persists more than 2-3 days

Question 52

What is the preferred technique for tracheal anastomosis? Why?

Answer 52

Split-cartilage technique Easier to perform Results in more precise anatomic alignment with less luminal stenosis (Best on dogs \>20lbs)

Question 53

Name some post-op complications that may occur after tracheal resection and anastomosis

Answer 53

Hemorrhage Voice change Fistula formation Cartilage malacia (not common) Excessive tension or neck movement can cause dehiscence (can cause SQ emphysema, acute respiratory distress, hemoptysis, SQ swelling) Excessive tension + healing by second intention -\> TRACHEAL STENOSIS Traumatizing recurrent laryngeal nerves -\> laryngospams, laryngeal paresis/paralysis

Question 54

What are the indications for permanent tracheostomy in the dog? What tissues are sutured in this “ostomy”? How is tension on this suture line reduced? What other procedure may be required in association with a permanent tracheostomy?

Answer 54

Moderate to severe respiratory distress caused by a UR obstruction - laryngeal paralysis, laryngeal collapse, neoplasia Skin is apposed to tracheal mucosa Reduce tension using tension-relieving sutures Placement on external rings adjacent to tracheostomy site might be needed if tracheal cartilage is soft

Question 55

T/F: Prognosis for dogs in generally better than cats post-permanent tracheostomy.

Answer 55

True

Question 56

What are the two primary surgical approaches to the thoracic cavity? Describe the advantages and disadvantages of each.

Answer 56

**Lateral/Intercostal thoracotomy:** used for directed approach to a specific structure in the thorax; less painful approach but time consuming and can be associated with rib fractures in small animals **Median sternotomy:** used for bilateral thoracic exploration, cranial mediastinal masses and to access the cranial thoracic trachea; more painful, and more invasive

Question 57

What approach would you use for a pneumonectomy?

Answer 57

Lateral intercostal

Question 58

Which nerves run along the dorsolateral aspect of the trachea?

Answer 58

Recurrent laryngeal nerves

Question 59

What kind of approach would you take for a ventriculocordectomy if you wish the dog the be **completely aphonic**?

Answer 59

Ventral

Question 60

T/F: To alleviate SQ edema, the most reliable method is to aspirate the air bubble with a needle and decompress the area.

Answer 60

False, usually not a single bubble but a collection of small ones so this usually doesn't work

Question 61

T/F: Most tracheal tears, even if minor, require immediate surgical intervention.

Answer 61

False, most minor tears resolve with medical management including cage rest, O2 supplementation, neck wraps and sedatives

Question 62

What modality is best for diagnosing tracheal stenosis?

Answer 62

Tracheoscopy

Question 63

Aside from tension, what causes post-op stricture after preforming a tracheal resection/anastomosis?

Answer 63

Inflammation Poor apposition of mucosa and skin

Question 64

What surgical approach would you use to explore the chest for a foreign body?

Answer 64

Median sternotomy

Question 65

What is the term for removal of all lobes of one lung?

Answer 65

Pneumonectomy

Question 66

T/F: Using staples instead of sutures in a lobectomy is preferred when the option exists and the patient size allows, because it decreases anesthesia and surgery time.

Answer 66

True

Question 67

T/F: Untwisting a lung torsion is the first step in any surgical repair.

Answer 67

False, NEVER untwist (otherwise risk reperfusion injury)

Question 68

On which side of the chest are partial lung lobe torsions possible?

Answer 68

Left

Question 69

What techniques can be used to perform a complete lobectomy? What methods can be used to perform a partial lobectomy?

Answer 69

_Complete_: Lateral thoracotomy or Thoracoscopy _Partial_: (Lateral 4th or 5th) Intercostal thoracotomy or Median sternotomy

Question 70

What are 2 possible causes of lung torsion? What is the typical signalment of a dog with lung lobe torsion? What lobes tend to be affected?

Answer 70

Pleural effusion Partial collapse of lung lobe _Sig_: Large, deep chested dogs (Afghan's) or Pugs _Large dogs_: middle or left cranial lobe _Pugs_: left cranial lobe

Question 71

A ___ (bulla/bleb)is located peripherally in the lung and easily seen. A \_\_\_(bulla/bleb) is deep in the lung, sometimes requiring attentive palpation to locate.

Answer 71

Bleb Bulla

Question 72

What breed is at increased risk for primary spontaneous pneumothorax?

Answer 72

Siberian huskies

Question 73

What are the 2 most common types of primary pulmonary neoplasia? Which has a better prognosis?

Answer 73

Adenocarcinoma (better prognosis) Squamous cell carinoma

Question 74

What injury is associated with hyperextension of the neck, such as high rise syndrome?

Answer 74

Tracheal transection/avulsion (usually at the level of the hilus)

Question 75

Why do animals with fractured ribs become hypoxic? What can you do to alleviate this condition?

Answer 75

Rib fractures may interfere with ventilation if the animal splints the thorax in an attempt to reduce pain by reducing motion of the fragments. Splinting can improve comfort

Question 76

What is the recommended treatment for a simple flail chest?

Answer 76

External splinting (thermoplastic material)

Question 77

Rapid deflation of lungs with open glottis produces a large pleuroperitoneal pressure gradient, resulting in a/an \_\_\_\_\_\_\_\_\_\_\_\_.

Answer 77

Diaphragmatic hernia

Question 78

T/F: Objects penetrating the chest wall should not be removed outside of the OR and after taking rads.

Answer 78

True

Question 79

Peritoneopericardial diaphragmatic hernias are always congenital in dogs and cats. Are these hernias inherited? What concomitant abnormalities may be found?

Answer 79

They might be, could be caused as a result of a teratogen, genetic defect, or prenatal injury. Cardiac abnormalities and sternal deformities

Question 80

Which organ, if it hernias into the chest makes a hernia repair an emergency?

Answer 80

Stomach

Question 81

What approach do you ALWAYS take when preforming a diaphragmatic herniorrhaphy?

Answer 81

Ventral midline abdominal approach

Question 82

What complication is most common associated with repairing a chronic diaphragmatic hernia?

Answer 82

Re-expansion pulmonary edema (fatal, no tx)

Question 83

What is the congenital deformity where there is inward concavity of the sternum? How is it treated?

Answer 83

Pectus Excavatum External splint

Question 84

What is the most commonly displaced organ with a diaphragmatic hernia?

Answer 84

Liver

Question 85

What is the landmark for a intercostal thoracotomy to access to cranial thoracic trachea? What if you needed to access the tracheal bifurcation or wanted to repair an avulsion?

Answer 85

Right 3rd ICS Right 4th ICS