upper airway Flashcards
(121 cards)
1
Q
nasal disease clinical signs
A
nasal discharge (uni or bi) sneeze reverse sneeze STERTOR epistaxis facial deformation ocular discharge
2
Q
disease of nasal cavity
- Anatomic
A
choanal atresia
3
Q
disease of nasal cavity
- inflammatory
A
rhinitis/sinusitis
Nasopharyngeal stenosis*
4
Q
disease of nasal cavity
- infectious
A
aspergillosis (dog)
cryptococcus (cat)
rhinosporidiosis
nasal mites
5
Q
disease of nasal cavity
- trauma
A
Trauma*
6
Q
disease of nasal cavity
- foreign body
A
foreign body
7
Q
disease of nasal cavity
- neoplasia
A
adenocarcinoma
squamous cell carcinoma
lymphoma
mast cell tumor
8
Q
Ddx of nasal disease
A
dental disease
nasopharyngeal polyps
9
Q
Best diagnostic for nasal disease
A
CT
10
Q
what should you always do before imaging? will bacterial culture help? and when should you PCR?
A
rhinoscopy and nasopharangoscopy
no
PCR for bartonella and mycoplasma
11
Q
Different nasal surgeries
A
nasal planum resection
reconstruction following trauma
rhinotomy
sinusotomy
12
Q
most common indication for nasal planum resection
A
Neoplasia
- SCC
13
Q
two ways rhinotomy can be done and what do they give you access to
A
Dorsal - access to nasal cavity and sinus
Ventral - access to ventral nasal cavity and choanae
14
Q
Sinusotomy
A
not really don’t anymore, radiation done instead because doesn’t change time
15
Q
Risks and complications with Nasal Surgery
A
Hemorrhage**
flap necrosis
oronasal fistula
dehiscence
stenosis of airways (without mucosal contact)
incomplete resection/local recurrence (for neoplasia)
16
Q
what causes does hemorrhage come from
A
dorsal, lateral and major palatine arteries
17
Q
what does local condrodysplasia result in
A
early ankylosis of basioccipital and basishenoid bones
shortened and broadened skull
18
Q
brachycephalic common dog breeds
A
English bulldog, French bulldogs, put, shih Tzu, Pekingese, Boston terrier, boxer
19
Q
brachycephalic less common breeds
A
chihuahua, cavalier skin Charles spaniel, Maltese, chow chow, yorkie, min pin, sharp pei
20
Q
brachycephalic cats
A
Persian
himilayan
21
Q
Primary disease components of brachycephalic airway syndrome
which is most important?
A
stenotic nares
elongated soft palate
everted laryngeal saccule/Stage 1 laryngeal collapse
+/- hypos plastic trachea
22
Q
BAS contributing problems
A
nasopharyngeal turbinates stage 2 or 3 laryngeal collapse tonsillar eversion (more edematous) tracheal collapse secondary edema macroglossia
23
Q
pathophysiology
A
higher negative pressure to overcome obstruction
secondary soft tissue changes
decreased air flow with increased obstruction
24
Q
what are the secondary sort tissue changes
A
edema
hyperplasia
collapse
25
air passage though nasal cavities counts for how much of nasal resistance
76.5%
26
____ should overlap the palate by 1-2 mm at midline
epiglotis
27
palate should extend to mid-ventral 1/3 of ____
tonsillar crypt laterally
28
Elongate soft palate results in mainly _____ causing _____
inspiratory dyspnea causing STERTOR
29
Elongated soft palate extending into rima glottides causes _____ and _____
severe obstruction and loss of protective laryngeal function
30
3 stages of Laryngeal Collapse
1- everted laryngeal sacccules
2 - collapse of uniform cartilage
3- collapse of corniculate cartilage
31
Chondromalacia
when stage 2 and 3 result of a loss of cartilage rigidity
32
Chondromalacia may cause
STRIDOR, but only in end stage
33
Laryngeal collapse is reported in ____% of dogs evaluated for BAS
8-50%
34
Hypospolastic Trachea is commonly seen in ___
English bulldog
35
Hypoplastic trachea signs
irregular, thick/firm cartilage rings, overlap of rings, increased airflow resistance
36
TX for hypoplastic trachea
No treatment
37
What is very common with BAS
GI comorbitites
38
GI comobirites
```
regard
vomit
hiatal hernia
pyloric hpertrophy
ulceration
lesions can go undetected by owner
```
39
what is a risk factor in pre and peri operative period
aspiration pneumonia
40
BAS clinical presentation
age: 2-3 (younger in English bulldog)
M>F
breed is dependent on region of country
41
BAS asymptomatic cs
young
less severely effected
owners doesn't realize
42
BAS mild/mod cs
exercise intolerance e
increased noise - snoring, snuffling, reverse sneezing
+/- gi signs (vomit after eating)
may have mild secondary changes
43
BAS severe
emergent basis in acute respiratory distress
severe upper airway swelling, hyperthermia, cyanosis
+/- heat stroke
+/- GI signs
+/- lower airway disease
non cariogenic pulmonary edema
aspiration pneumonia
numerous secondary changes (stage 1 laryngeal collapse and maybe 2 or 3)
usually older
44
BAS ddx
space occupying mass of upper airway --> neoplasia, abscess, granuloma, foreign body, epiglottic retroversion
45
Diagnostics - Radiographs
```
good to pull out other things
right heart enlarged
hypoplastic trachea
non-cardiogeinc pulmonary edema
aspiration pnuemonia
hiatal hernia (may need contrast)
megaesphogus
```
46
how would you assess for hypo plastic trachea on radiographs
tracheal lumen: thoracic inlet ratio
47
what may megaesophagus be associated with
reflux esophagitis
48
best diagnostic for BAS
upper airway exam
49
Diagnosics when considering comorbidites
blood work
abdominal radiographs
lateral cervical radiographs
50
Drugs to avoid in upper airway exam bc then can affect laryngeal function
ketamine
diazepam
large doses of pure u agonists
acepromazine
51
what drugs should you use in upper airway exam
propofol alone, then you can give sedative/opiod after exam
52
what drug would you use in upper airways exam if you want to improve rate and strength of respiration
Doxapram 1.2 mg/kg (or dopram)
| general CNS stimulant
53
use same order when doing upper airway exam
tonsils > soft palate > nasopharanx > arytenoid cartilage > (laryngeal function, mucosal lesions, excess mucous/saliva, masses) > evaluate nares
54
when is treatment necessary for BAS
if there is precent of any of th4e comments
upper airway exam should be done at spay/nueter
sx intervention to prevent secondary changes
animal with clinical signs
55
sugeries for treatment of BAS
soft palate resection (staphylectomy)
excision of everted laryngeal saccules
Wedge resection (nares)
spay/nueter
correction
56
preop therapy considerations
GI protectant and promotability
Anti-inflammatory
anti emetic at time of premed for anes
pre oxygenate prior to induction
57
GI protectant and promotability
unknown if it decreased risk of aspiration pneumonia
of symptomatic treat 10-14 days prior to sx
famotidne, pantaprazole, metocloprimide
58
Anti-inflammatory
for soft palate resection/everted saccule excision
| dexamethasone at induction
59
anti emetic at time of premed for anes
cerenia (maropitant)
60
how do you surgically position for BAS
maxilla hanging from IV poles
+/- mourn gag
endotracheal intubation (ensure cuff adequately inflated)
gauze packing of larynx
61
diff ways to do staphylectomy soft palate resection
sharp dissection
CO2 laser excision
bipolar sealing device excision
62
Staphlectomy - what landmarks do you used to determine level of excision?
midline- don't wanna make it shorter than epiglottis
- if you make it too short then you will have nasal reflux every time they eat food will go
lateral - level of tonsilar crips
63
freehand / "cut and sew" technique
amputate soft palate to midline with scissors on one side suture to midline, amputate remaining palate and suture
bleeding stops as u cut
stay suture
64
laser freehand technique
rapid, visually no blood loss, excellent visulization, minimal post op infl.(steroids help) reduced post op discomfort?
Disadvantage: flammable
- saline soak gauze and put around endotrach
65
folded flap palatoplasty
when palate is thick
excision of part of the oropharyngeal soft palate and underlying muscle
nasopharyngeal side folded forward and sutured to the oropharyngeal border resulting in both shortening and thinning of palate
66
complications of staphylectomy
acute
- hemorrhage
- infl.
chronic
- undershortening > redo
over shortening ***
- nasal reflux
- aspiration
67
TX excision of everted laryngeal saccule
excision with scissors, heals by second intention (no suture)
68
TX stenotic nares
```
wedge resection
- horizontal
- vertical
- dorsolateral
amputation
alapexy
```
usually leave for end so you can have endo trach tube in longer
69
why so many techniques for stenotic nares
severity of collapse
static vs dynamic
comestic (least imp)
70
vertical wedge needs to be deep enough to
lateralize alar fold
71
Traders technique - alar wing amputation
cold steel
electosurgery
laser
amputate alar wing and alar fold as needed to create adequate opening
72
SX for stage to laryngeal collapse
partial arytenoidectomy
ventriculochordectomy
also correct other abnormalities
73
complications with partial arytenoidectomy
| ventriculochordectomy and how it can be avoided
webbing or strictures
avoided by NOT cutting to the ventral and dorsal extents of the circulate processes and vocal folds
74
ventral webbing is also an issue for _____ and _____
vocal fold excision and debarking
75
SX for Stage 3 laryngeal collapse and two considerations
permanent tracheostomy
- hypoplastic trachea
- loose skin folds
76
which SX is not recommend
tonsillectomy
77
SX only for laryngeal paralysis and if adequate cartilage rigidity is present
Unilateral arytenoid lateralization
- must distinguish btwn laryngeal paralysis and laryngeal collapse
78
SX if clinical improvement not seen of if decompensation occurs later
temporary or permeant tracheostomy
79
post op care
```
+/- Nasal O2
Avoid overheating
Leave intubated as long as
possible
Sternal recumbency with
head up
Analgesia >Buprenorphine
+/- Sedation
Additional antiinflammatories
NPO for ~ 24 hours
Treatment of GI signs
E-collar
```
80
medical tx
```
Weight loss
Environmental changes
Cool environment
Activity changes
Exposure to respiratory
irritants
Harness
Treat underlying GI
disease
Should be instituted for
every brachycephalic
patient!
```
81
Severe post op complications
```
Pharyngeal / Laryngeal
Swelling
- Acute distress
- May require emergency tracheostomy
Vomiting
Regurgitation
ASPIRATION PNEUMONIA**
```
82
Minor post op complications
```
Dehiscence of nares
- Recurrenceof stenosis
Bleeding
Persistent stertor/stridor
Rhinitis/Sinusitis
Voice Change
```
83
which component os BAS has poorest outcome
none
84
clinical improvement tin dogs with
stage 2-3 laryngeal collapse
85
success rate of ___ but ____
61-94% but ALL WILL STILL SNORE
86
morality rate
3.2 - 6.8%
87
_____ secondary to aspiration pneumonia
English bulldog
88
Epiglottic retroversion presents with upper airway obstruction .. what is suspected cause?
Laxity of hyoepiglotticus m. in face of extreme inspiratory effort
89
DX of epiglottic retroversion
sedated laryngeal exam
90
TX for epiglottic retroversion
surgical pexy of the ventral aspect of the epiglottis and the dorsal base of the tongue
91
if patient I showing signs of upper air way obstruction what should be preformed
laryngeal exam
92
TX for laryngeal neoplasia
Partial or total laryngectomy
| Permanent tracheostomy and gastrostomy tube will also be required in many cases
93
TX for foreign body
removed via endoscopy, transorally, or via
| ventral approach to larynx
94
intrinsic muscle responsable for laryngeal abduction
crycoarytenoideus dorsalis
95
innervation: ______ sensory and ________ motor
cranial and caudal laryngeal never
96
Origin of cranial laryngeal nerve
vagus
97
Origin of caudal laryngeal nerve
vagus > recurrent laryngeal > caudal laryngeal
98
Functions of the larynx
swollowing
- Rima glottis pulled forward and occluded by epiglottis
adbuction
- Decreases airway resistance during inhalation
- Adduction during exhalation is passive
voice production
- via changing tension on vocal cords
99
Diseases of the Larynx
```
Laryngeal Paralysis **
Laryngeal Collapse
Neoplasia (Rare)
Cysts
Trauma **
Foreign Bodies
Laryngeal Web Formation
```
100
Clinical Signs of Laryngeal
| Disease
```
Respiratory STRIDOR
Exercise intolerance
Gagging/Dysphagia
Dysphonia (voice change)
Coughing
Dyspnea that does not improve with open mouth breathing
```
101
Congenital Laryngeal Paralysis
| Bouvier de Flandres, Huskies, bull terriers, Dalmations
Progressive degeneration of
neurons with onset before 1 year
May have signs associated with
cranial tibial muscle paralysis
102
Congenital Laryngeal Paralysis
| rotties
```
Progressive generalized degenerative disease
Onset of signs between 11 and 13weeks
Ataxia, paresis, head tremors,
neurogenic muscle atrophy
Grave prognosis
```
103
Acquired Laryngeal Paralysis
| breed?
lab
| large, older (9 yrs)
104
what is essential in dx Acquired Laryngeal Paralysis
Complete PE and neurologic exam
105
what neuropathy do dogs get with Acquired Laryngeal Paralysis
Geriatric onset laryngeal paralysis polyneuropathy (GOLPP)
106
what is the most common cause of Acquired Laryngeal Paralysis
```
Idiopathic polyneuropathy
• Hypothyroidism
• Trauma
• Immune Mediated (myasthenia gravis)
• Infectious
• Toxin (lead, organophosphates)
```
107
Acquired Laryngeal Paralysis are similar to
laryngeal dz
| Increased incidence of gastroesophageal reflux
108
Acquired Laryngeal Paralysis -what emergency cars may be needed at presentation
Sedation vs. anesthesia
Cooling for hyperthermia
intubation > temporary tracheostomy
Supportive care
109
Diagnostics for Acquired Laryngeal Paralysis
```
Thoracic Radiographs (3 views)
Lateral cervical radiographs
CBC, Chemistry, UA, TSH and
T4
Esophagograhic evaluation
Electrodiagnostics? EMG, NCV
Acetylcholine receptor antibody
titer? Thymoma associated myasthenia
gravis
```
110
what are you looking for on radiographs
```
Aspiration pneumonia
Megaesophagus
Cranial mediastinal masses
- Thymoma
Non-cardiogenic pulmonary edema
```
111
Laryngeal exam
propofol only
Arytenoids should abduct on inspiration
Assistance required for monitoring of respiratory cycle
- Watch for paradoxical motion
- Be prepared to proceed immediately with further diagnostics or surgery based on findings***
Ultrasonography
Tracheoscopy/BAL as indicated
112
medical TX Acquired Laryngeal Paralysis
for mild signs but educate owners about dz progression
113
Acquired Laryngeal Paralysis TX regardless of severity
sx - unilateral arytenoid lateralization
114
unilateral arytenoid lateralization
Decreases airway resistance during inspiration by widening the rima glottidis
Use of oversized endotracheal tube helpful for achieving appropriate abduction
Excessive tension may increase risk of aspiration pneumonia due to poor epiglottic coverage of rima glottidis
115
Unilateral Arytenoid Lateralization
| Poiseuille’s Law:
In laminar flow resistance to flow is inversely proportional to the radius to the fourth power
116
Arytenoid Lateralization Goal of sx
Unilateral “Low tension”
117
Unilateral Arytenoid Lateralization
| Post-op Care
Maintain ET tube until patient is sufficiently awake
get awake as quickly as possible
Avoid heavy sedation or medications that may incite
nausea/vomiting
Opioids associated with increased risk of aspiration
pneumonia
NPO for 24 hours post-op
- Allow small amounts of water and 3-4 hand rolled meatballs
with close monitoring
Monitor carefully for signs of aspiration pneumonia
118
how to Monitor for signs of aspiration pneumonia
Hyperthermia
Cough
Dyspnea
Increased respiratory effort
Perform arterial blood gas or venous blood gas as well as
thoracic radiographs to confirm diagnosis
119
Unilateral Arytenoid Lateralization
| Complications and Outcomes
```
aspiration pneumonia***
- life long risk
recurrent or persistent signs
- may req sx on contralat side
Seroma, intramural hematoma, coughing, gagging, dysphagia
- Dependent on age at time of SX
```
120
SX for devocalization
Ventriculocordectomy
121
Ventriculocordectomy
```
Controversial
• Behavioral evaluation/modification should be attempted prior to surgery
Transoral and ventral* approach
Important to leave 1-2 mm
ventral cord intact to decrease
risk of webbing (cover area with mucosa)
Some phonation ability may
persist or return over time
```
