Flashcards in Surgical Conditions of the Airway Deck (68):
Most common conditions of the nasal planum?
- very haemorhagic
- pressure or suturing may be required
2. congenital deformities
- stenotic nares
- cleft/hare lip (1* palate cleft) occassionaly causes nasal discharge
3. neoplasia - often unilateral: ulceration or epistaxis
- SCC (erosive in cats, but responsive to wide loval excision and radiation tx)
- MCT (requires adjunctive chemo)
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
Emergency Tx of BCAD?
- cool IV fluids
- whole body cooling
- 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
- aspiration pneumonia
Aetiology of laryngeal paralysis?
1. Congenital (rare) - bouvier des FLandes and huskys
2. Acquired (KNown) - trauma, neoplasia (mediastinal, thyroid), 2* to polyneuropathy/polymyopathy (hypothyroidism, RLN problems etc.)
3. 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?
- 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?
- 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?
1. chronic hyperplastic rhinitis (prolonged inflam and ^ mucous secretion, more common in whippets, daschunds and cats)
3. dental diseasse (mucopurulent discharge, occasional epistaxis, unilateral, periapical lucency on radiographs and oral lesions)
4. intranasal neoplasia (most malignant = solid carcinoma/adenocarcinoma, chondro/fibro/osteo sarcoma; benign polypoid rhinitis rare but if differentiated on histo prognosis good)
5. Mycotic rhinitis (aspergillus, Penicillium)
6. 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
- rhinotomy for confirmation/therapy
What 2 types of defects in the 2* palate are possible?
- 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)
- 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
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)
- lymphoma (Cat)
CLinical signs of laryngeal neoplasia
- 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
What condition are small toy breeds predisposed to? What may exaccerbate this ? When do they commonly present?
- 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
- 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)
- only good for old animals
- granulation tissue will form over stent and narrow airway
- 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.
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?
- majority are malignant adenocarcinoma
Clinical signs of lung tumour?
- cough and haemoptysis
- 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?
- 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?
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?
- 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?
1. stomach returned to abdo, phrenoesophageal ligament gently dissected free
2. defect closed and esophopexy sutures between ventrolateral oesophagus and diaphragmatic hiatus placed (2-3cm diameter, normal position)
3. 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