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3. Cat & Dog 3 > Upper Resp Surgery > Flashcards

Upper Resp Surgery Flashcards

1
Q

Brachycephalic Obstructive Airway Syndrome -Pathophysiology

A
  • Congenital malformation
  • Skull bones normal width but shortened length
    > but still have all the same soft tissue!
    <><><><>
    Bony changes > Soft tissue excess > Upper airway obstruction
    <><>
    “Breathing through a straw”
    <><>
    increased Airway resistance =
    increased Negative P needed to maintain airflow
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2
Q

primary and secondary issues associated with BOAS

A

Primary:
- Stenotic nares
- Elongated soft palate
- Hypoplastic trachea
<><><><>
Secondary:
- Everted laryngeal saccules
- Tonsillar eversion
- Laryngeal Collapse

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3
Q

why are brachycephalics more susceptible to hiatal hernias? what outward clinical signs can be associated? significance?

A
  • dog is lip smacking
  • they have been gasping for air their whole life, negative pressure sucks stomach into chest
    > assume most frenchies have it
    > but they dont all need surgery for it
  • creates a lot of silent regurgitation, which is where this lip smacking may come from
    <><><><>
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4
Q

Brachycephalic Obstructive Airway Syndrome -Possible GI signs

A

GI signs - regurgitation or vomiting
> Hiatal hernia
> Aerophagia
> Pyloric outflow

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5
Q

Brachycephalic Obstructive Airway Syndrome
-Pathophysiology of how laryngeal edema can arise

A
  • Elongated soft palate, stenotic nares
    > Increased inspiratory pressure
    > Eversion of laryngeal saccules, soft palate stretching
    > Further increased inspiratory pressure
    > Laryngeal edema, eventual collapse
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6
Q

stages of laryngeal collapse

A

Stage I:
Eversion of laryngeal saccules without paradoxical collapse or corniculate or cuneiform processes
<><>
Stage II:
Medial displacement of the cuneiform processes during inspiration
<><>
Stage III:
Collapse or the corniculate processes with loss of the dorsal arch of the rim

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7
Q

Brachycephalic Obstructive Airway Syndrome
-Emergency Management

A
  • Oxygen supplementation
  • Sedation (acepromazine 0.02-0.05 mg/kg IV or IM)
  • Cooling
  • Calm environment
    <><>
    If no improvement in a few minutes:
  • Intubation
  • Temporary tracheostomy
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8
Q

Brachycephalic Obstructive Airway Syndrome -Which components can be addressed surgically? which cannot?

A

Can be addressed surgically:
- Elongated soft palate
- Stenotic nares
- Everted laryngeal saccules
<><><><>
Cannot be:
- Hypoplastic trachea
<><><><><><><>
- Laryngeal collapse?- dont want it to get to this point
- difficult as complete tracheostomy is the only option

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9
Q

Brachycephalic Obstructive Airway Syndrome -Respiratory signs

A
  • Stertor
  • Stridor
  • “Choking” / Gagging
  • Collapse
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10
Q

Brachycephalic Obstructive Airway Syndrome
-Diagnosis

A

Sedated / light plane of anesthesia airway exam
> no need to do this unless planning surgery
<><><><>
Intubate
+/- Bloodwork
Thoracic radiographs
Head CT

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11
Q

Brachycephalic Obstructive Airway Syndrome
-Surgical management
- who is a candidate?
- risks?

A
  • Dogs in moderate to severe respiratory distress and those with exercise intolerance are candidates
    <><><><>
  • BEWARE! Mortality from retrospective studies is 3.2-7%
  • Inform owners fully of complications
  • MY OPINION: Do not perform BOAS surgery if 24 hour care not possible
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12
Q

Brachycephalic Obstructive Airway Syndrome
- surgical approach

A
  • Alar fold vestibuloplasty (NARES) FIRST
  • Intra-oral procedures
    > Tonsillectomy
    > Folded flap palatoplasty…or aggressive palate surgery
    > Sacculectomy
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13
Q

Brachycephalic Obstructive Airway Syndrome -Stenotic nares
Should I address stenotic nares at the time of OVH / neuter?

A

> wont necessarily hurt, but not going to save it from further surgery down the road… this is not the only component of BOAS, so wont necessarily be effective

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14
Q

surgical correction techniques for stenotic nares, considerations

A
  • Vertical wedge resection
    > #11 blade
    > Cotton-tipped applicators and/or gauze
    > Nasal cartilage highly vascular!
    > big chunk of tissue further back that we are not addressing with the vertical wedge
    <><>
  • Alar Fold Vestibuloplasty
    > take much larger piece, going deeper
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15
Q

should we do a tonsilectomy for BOAS cases? why?

A

amit does it for most cases - any tissue that could get sucked into airway could be an issue

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16
Q

-Elongated soft palate
- how do we surgically correct this?

A

Traditional landmark:
- Soft palate should not extend beyond tip of epiglottis
<><><><>
“cut the palate to the tip of the epiglottis” - is what we see in textbooks, but this can be hard to see with intubation
- amit has realized that this palate needs to be totally open…
> we need to be very very aggressive > you cannot take to much of it!!!!
- the cranial aspect of the tonsil is a fair place to take it to

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17
Q

Staphylectomy procedure

A
  • Pull soft palate rostrally with stay sutures or forceps
  • Cut soft palate to midline, then suture in continuous pattern
  • Cut second half and finish suture line
  • FULL THICKNESS BITES
  • ATRAUMATIC TECHNIQUE
18
Q

Folded Flap Palatoplasty
- how to perform
- complications

A
  • 2x stay sutures On edge of soft palate
  • -Removal of oropharyngeal mucosa / muscle
  • Monopolar Electrosurgery
  • -Suturing of flap
    <><><><>
    Overall low rate
  • Incisional dehiscence
  • Perforation of flap
19
Q

-Everted laryngeal saccules
- are secondary to what? what is this?

A
  • Secondary to increased negative airway pressure
  • Mucosa covering laryngeal ventricle everts
  • “Inside out pant pockets”
20
Q

-Everted laryngeal saccules: how to fix surgically

A
  • Visible at 5 and 7 o clock
  • Grasp with forceps and cut base of saccule with long handled Metzenbaum scissors
  • Single cut ideal
  • Suture not required
  • ATRAUMATIC
  • Be weary vocal fold caudal to
21
Q

when to extubate brachycephalics?

A

make sure they wide awake before you pull the tube!

22
Q

Brachycephalic Obstructive Airway Syndrome -Postoperative treatment

A
  • Corticosteroids - anti-inflammatory
    > Dexamethasone
  • Brachy “cocktail”
  • NPO 24hrs postoperatively
    +/- Oxgyen supplementation
    +/- Sedation
  • Be prepared for re-intubation +/- tracheostomy
  • Calm, cool environment
23
Q

brachycephalic felines - what is the main airway issue?

A

Stenotic nares appears to be the only component of BOAS

24
Q

BOAS in felines solution

A

vestibuloplasty has worked out well
> they only have stenotic nares as the adverse component

25
Q

Brachycephalic Obstructive Airway Syndrome -Take home messages

A
  • Be aggressive with palate and nares
  • Same day DC??
  • Owner education essential
26
Q

FUNCTIONS OF THE LARYNX
- what governs function?

A
  • Regulate airflow
  • Assist in voice production
  • Prevent inhalation of food
  • Laryngeal function governed by intrinsic muscles and nerve supply
27
Q

pathogenesis of larygeal paralysis

A
  • Only abductor of the larynx is cricoarytenoideus dorsalis (CAD) - opens rima glottidis
  • Recurrent laryngeal n innervates all intrinsic muscles of larynx aside from cricothyroideus m.
    <><><><>
  • Cricoarytenoideus dorsalis fails to contract
  • Arytenoid cartilages fail to abduct
  • Rima glottidis obstruction occurs
  • Increased resistance to airflow
  • Increased speed of airflow
  • Decreased intraglottic pressure
  • Laryngeal collapse
  • Increased resistance to airflow….
28
Q

who is most affected by laryngeal paralysis? etiology?

A
  • Large breed dogs! almost exclusivery labs, 10-11 years old
    <><><><>
    Congenital (<1yr)
  • Bouvier, Dalmation, Rottweiler, Siberian Husky
  • Wallerian degeneration of nucleus ambiguous
    <><><>
  • Acquired
  • Idiopathic (old dogs with polyneuropathy
29
Q

IDIOPATHIC LARYNGEAL PARALYSIS - prevalence
- origins?

A
  • Most common
  • Early manifestation of a systemic polyneuropathy
  • GOLPP - geriatric onset laryngeal paralysis polyneuropathy
30
Q

laryngeal paralysis common historical findings

A
  • Progressive signs
  • Change in bark
  • Coughing, gagging
  • Exercise intolerance
  • Inspiratory stridor
  • Dyspnea, collapse
  • Male>Female
31
Q

laryngial paralysis usual method of diagnosis

A
  • Exam room diagnosis!!
  • High index of suspicion based on history, signalment and clinical signs
  • Neurological exam
  • Thoracic radiographs and abdominal ultrasound
    <><><><>
  • dont necessarily need an airway exam, can often tell in exam room with history, breed…
  • upper airway exam can be used to confirm, vs tumor or mass… but not super needed
32
Q

thoracic radiographs for laryngeal paralysis purpose?

A
  • Baseline!
    Check for:
  • Aspiration pneumonia
  • Cranial mediastinal mass
  • Megaesophagus
  • Others
    <><>
    but maybe we dont want to put these airway dogs in lateral recumbency
33
Q

laryngeal paralysis - how to diagnose with larygoscope? considerations?

A
  • Laryngoscopic evaluation under a LIGHT PLANE of anesthesia
  • Evaluate arytenoid function and appearance
  • Beware false positives…many anesthetic drugs can inhibit arytenoid function
  • Doxopram - Be ready to intubate!
  • Have an assistant identify aspiration and expiration (in, out, in…)
  • Paradoxical movement of arytenoids
34
Q

ANESTHESIA FOR LARYNGOSCOPY - drug of choice?
what drugs affect arytenoid function?

A
  • Propofol is drug of choice for injectable induction
  • Acepromazine depresses arytenoid function
  • Doxopram increases arytenoid function
35
Q

SURGICAL TREATMENT for laryngeal paralysis
- when do we do this?
- goal?

A
  • For dogs with severe respiratory stridor
  • Unilateral cases may not need surgery
  • Ideal for pneumonia (or edema) to resolve prior to sx
    <><>
  • Goal - enlarge rima glottidis area to decrease resistance of airflow while not increasing risk of asp. pneumonia
36
Q

surgical procedure for correction of larygeal paralysis

A
  • Unilateral arytenoid lateralization
  • 1-2 sutures from cricoid through arytenoid at level of crico-arytenoid joint
  • Prevents inward motion of arytenoid during inspiration
    <><>
    > aretynoid will be permanently open, which is not super great for all purposes…
  • only do unilateral! lots of mortality from aspiration penumonia if bilateral
37
Q

larygeal paralysis surgery
* Unilateral arytenoid lateralization
intraoperative complications

A
  • Careful passage of needle through arytenoid cartilage
  • Brittle cartilage predisposed to fracture
  • If fracture can try to pass again or perform UAL on R
    <><><><>
  • Surgical approach can be challenging
  • Palpate for wing of thyroid cartilage
38
Q

POST-OPERATIVE COMPLICATIONS for Unilateral arytenoid lateralization

A

Immediate / Short term:
* Inadequate lateralization
* Suture breakage
* Seroma formation
<><>
* Aspiration pneumonia
* Coughing & Irritation

39
Q

aspiration pneumonia after surgery for larygeal paralysis - how common over time? drug factors influencing?
- can we do anything to help?

A
  • 1 year - 18.6%
  • 2 year - 27.2%
  • 3 year - 31.8%
  • Risk of aspiration pneumonia increase w PO opioids
  • DO: Line block w bupivacaine at surgical site
  • Allows dogs to regain sternal recumbency rapidly
40
Q

Unilateral arytenoid lateralization
- post operative care

A
  • NPO for 12 - 24hrs after surgery
  • Maintain on IV fluids overnight
  • Give small quantities of ice chips or water morning after surgery
  • If water tolerated small quantities of food meatballs can be re-introduced
  • Feed small moist meatballs initially for 14 days - Continue to avoid stress
41
Q

care after discharge for Unilateral arytenoid lateralization

A
  • Exercise restriction for 4 - 6 weeks
  • Avoid neck leashes
  • Council owners as to life-long predisposition to aspiration pneumonia
  • Care if further anesthesia procedures required
  • Follow-up treatment for aspiration pneumonia if present
42
Q

is surgery a decent options for laryngeal paralysis? prognosis?

A
  • Majority of dogs having sx will greatly improve!
  • Low perioperative morbidity - non-invasive procedure
  • Client education critical
  • Aspiration pneumonia
    > Not necessarily fatal

3. Cat & Dog 3 (26 decks)

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