Joe Palamara, DVM, DACVS-SA Description: Dyspnea is defined as difficulty/labored breathing or shortness of breath, and can be a sign of serious disease of the airway, lungs or heart. This lecture will review the process of diagnosing, stabilizing and further localizing dyspnea in dogs. We will discuss recommendations for surgical correction of components of Brachycephalic Airway Syndrome, as well as salvage procedure for Laryngeal paralysis. With appropriate management, the prognosis for these conditions is generally favorable depending on the degree of severity. Learning Objectives ­ - Recognize the clinical signs, associated physiology, and diagnosis related to each condition ­ - Initial stabilization for patients presenting in airway crisis ­ - Understand the medical and surgical options for each condition

1. JOSEPH PALAMARA, DVM,
DACVS-SA
JUNE 1,
2019
THE DYSPNEIC DOG

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 Part 1. Review dyspnea of the upper airway
 Part 2. Examination of the upper airway
 Part 3. Brachycephalic obstructive airway syndrome
 Part 4. Laryngeal paralysis
OBJECTIVES
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DYSPNEIC DOG
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DEFINITIONS
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 Definition
 Difficulty or labored breathing
 Clinical Signs
 Tachypnea (increased rate of respiration)
 Hyperpnea (increased depth of respiration +/- accompanied by increase in rate)
 Hyperventilation
 Panting
DYSPNEA
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 Respiration
 Controlled under normal conditions
by arterial CO2 (PaCO2)
 PaCO2 is kept under tight control (+ 3mmHg)
 Triggers of respiratory distress
 Hypoxemia (PaO2 <50-60 mmHg)
 Hypercapnia/hypercarbia (PaCO2 >50 mmHg)
DYSPNEA
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 Chronic hypoxemia
in dogs with
chronic airway obstruction
(ex. Laryngeal paralysis)
DYSPNEA
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PATHOPHYSIOLOGY OF DYSPNEA
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DYSPNEA
PRIMARY
RESPIRATORY
CAUSES
UPPER
AIRWAY
DISEASE
LOWER
AIRWAY
DISEASE
NONRESPIRATORY
CAUSES
PULMONARY
VASCULAR TONE
CNS
SHOCK
PULMONARY
CIRCULATION
CHF
PTE
OXYGENATION
METHEMOGLOBINEMIA ANEMIA
VENTILATION
OBESITY
ASCITES
ABDOMINAL
ORGANOMEGLAY

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CAUSES OF DYSPNEA - ANATOMIC
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DEFINITIONS
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 *Similarities
 Both involve turbulence of airflow in the respiratory tract
 Stertor
 Respiratory sound characterized by snoring or gasping upon inspiration
 Site--Nasopharyngeal, Palatal
 Stridor
 Respiratory sound, usually high pitched, generated by the larynx during inspiration
 Site--Laryngeal
STERTOR VERSUS STRIDOR
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STERTOR VERSUS STRIDOR
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STERTOR
STRIDOR

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ANATOMY OF THE RESPIRATORY SYSTEM
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1. Posterior nares
2. Pharynx
3. Larynx
4. Trachea
5. Right lung
6. Heart
7. Diaphragm
8. Esophagus
9. Termination of the trachea
Upper Airway
Lower Airway

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Airways
Nares, nasopharynx, oropharynx, pharynx,
larynx, trachea
Pulmonary parenchyma
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ANATOMIC LOCATIONS OF RESPIRATORY DYSPNEA

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 Respiration versus deglutition
 Protection of the airway
by the epiglottis
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“CROSSROADS”
LUNGS NOSE

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 Identify respiratory distress
 Stabilize the patient
 Determine anatomical origin
of respiratory distress
PATIENT ASSESSMENT
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 Presenting complaint:
 Trouble breathing
OXYGEN SUPPLEMENATION
…then
PATIENT PRESENTATION
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 MEDICAL STABILIZATION:
 Cool environment
 Supplemental oxygen
 IV fluids (mindful of pulmonary edema)
 Sedation
 Acepromazine (0.01-0.05 mg/kg IV), butorphanol (0.2 mg/kg IV),
 Anti-inflammatory
 Dexamethasone (0.1-0.2 mg/kg IV)
 Temporary tracheostomy and laryngeal surgery (if indicated)
 Negative prognostic indicator, more postoperative complications
PATIENT PRESENTATION
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Upper Airway
Lower Airway
PATIENT ASSESSMENT
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 Determine anatomical origin
of respiratory distress
THINK…

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PATIENT ASSESSMENT
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 Objectives of retrospective study
 Determine the most frequent underlying diseases in dogs
presenting with dyspnea
 Determine if signalment, nature, and duration of clinical signs
might help in assessment of the possible underlying condition and
prognosis

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Groups 1-5
 Group 1 Upper airway disease
 BOAS, laryngeal paralysis, tracheal collapse, neoplasia
 Group 2 Lower respiratory tract
 Pulmonary parenchymal disease (inflammatory, infectious, neoplasia), noncardiogenic pulmonary edema, bronchial disease, PTE,
DIC, ARDS, coagulopathies
 Group 3 Pleural space disease
 Pleural effusion (idiopathic, secondary to systemic disease or lung lobe torsion, and neoplasia), pneumothorax, pyothorax,
neoplasia (thymoma, thymic, ectopic thyroid carcinoma), and PPDH
 Group 4 Cardiac disease
 Acquired and congenital cardiac diseases casing pulmonary edema, pleural effusion, or both and pericardial effusion Iidiopathic
and neoplasia) associated with pleural effusion
 Group 5 Obesity or Stress
 NO underlying disease detected
 BCS > 7/9
PATIENT ASSESSMENT
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 Incidence
 # of patients = 1.7% (229/13293) of patients presented to ER 2o to dyspnea
 Localization
 Most frequent underlying diseases in dogs presenting with dyspnea
• Lower airway (33%) Pleural space disease (19%)
• Upper airway (32%) Cardiac disease (12%)
Obesity and stress (4%)
INCIDENCE AND ANATOMIC SITES
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65% occurred at lower or upper airway

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 Most frequent underlying diseases in dogs presenting w dyspnea
DISTRIBUTION / ETIOLOGY
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IDENTIFYING ANATOMIC SITE
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Emergency
Presentation
Cardiac
Pleural Space
Lower
Respiratory Tract
Shorter duration of clinical
signs
(median, 3 days)

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IDENTIFYING ANATOMIC SITE
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Emergency
Presentation
Upper
Respiratory Tract
Longer duration of clinical signs
(median, 49 days)

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 Breeds of Upper airway disease patients
 BOAS
 72% of patients were Bulldogs, Pugs, CKCS
 Laryngeal paralysis
 55% of patients were Mixed breeds, Labs, English Bulldogs
 Tracheal collapse
 70% of patients were Yorkies, Toy Poodles
BREED PREDISPOSITION
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 Distribution of ages and breeds in study
 All dyspneic dogs in the study (median age, 6 yrs)
 Bulldogs were significantly younger
(median age, < 2 years)
 Mixed-breed dogs, Golden Retrievers were significantly older
(median age, > 8 years)
SIGNALMENT
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 Medical versus surgical management
 Duration of signs in dogs requiring surgical management
(median, 42 days)
 Duration of signs in dogs requiring medical management
(median, 7 days)
DURATION OF SIGNS / TREATMENT
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 BOAS – 31% (12/39) were emergent
 79.5% (31/39) had surgery 84.6% (33/39) survived
 Laryngeal paralysis – 64% (14/22) were emergent
 82% (18/22) had surgery 77% (17/22) survived
SURGICAL MANAGEMENT /
UPPER AIRWAY PATIENTS
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 A greater proportion of dogs 82% (62/76) that underwent
surgical management were discharged than those receiving
medical treatment 48% (74/153)
 Survival of all patients in the study with dyspnea 60% (135/229)
PROGNOSIS FOR SURGICAL PATIENTS
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 Breed conformational causes of dyspnea
 Easily identifiable
 Brachycephalic breed
 Younger age
 Less emergent cases / most stable
 Longer duration of clinical signs
 Better outcome versus other causes of dyspnea
 Surgery significantly improved outcome
SUMMARY OF UPPER AIRWAY PATIENTS
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Lung parenchyma
Cardiac
Systemic causes
Breed conformational changes
Airway obstruction
Pleural space diseases
-------- Surgical --------
-------- Medical --------
DYSPNEA

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 Please be alert to:
Acute decompensation (i.e. in a stressful
situation) and emergency examination of a
previously stable patient is possible and should
not be underestimated
SUMMARY OF UPPER AIRWAY PATIENTS
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DYSPNEIC DOG
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PHYSICAL AND UPPER AIRWAY EXAMS
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 General physical exam
 History
 Respiratory-related signs or issues? Phonation changes? Duration? Severity? Cyanosis?
 Chance to play “name that sound” – reverse sneeze, stertor, stridor, hacking cough
 Physical exam
 Head exam – nose, eyes, ears, lymph nodes
 Cursory oral exam – ulcers (oral/ocular), discharge (ocular/nasal), airflow (oral/nasal),
dental disease, palate (deviation?), tonsils (eversion?)
 Neck palpation (cervical tumors?), thoracic auscultation, etc
PHYSICAL EXAM
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UPPER AIRWAY EXAMINATION
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UVS SETUP
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 Pre-oxygenation x 5-10 minutes
 IV catheterization (cephalic)
 All materials prepared and setup
 Laryngoscope, various ET tube sizes,
muzzle gauze, tongue depressor
 Medications…?
PROTOCOL
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Premed?
Sedative/Induction?

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 Evaluation of the arytenoid movement
 The ideal anesthetic protocol = maintain intact laryngeal
reflexes while achieving an anesthetic depth sufficient to allow
for jaw relaxation
 Challenge = even light anesthesia may result in apnea or shallow
inspirations, confounding an accurate diagnosis
GOAL OF LARYNGEAL EXAM
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 Options
 Propofol to effect (~6-7ml/kg)
 Alfaxalone to effect (~2mg/kg)
 +/- Butorphanol + Acepromazine premedications
 What’s best?
SEDATION PROTOCOLS
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SEDATION PROTOCOLS
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 Doxapram (Dopram)
 Central nervous stimulant that transiently increases respiratory rate and tidal volume
by increasing electrical activity in the inspiratory and expiratory centers of the
medulla
 May also stimulate respiration by reflex activation of carotid and aortic
chemoreceptors (Plumb 2002).
 Administration normal dogs results
 Increased respiratory effort and depth, and intrinsic laryngeal motion
 Administration to dog with laryngeal paralysis
 Vigorous, paradoxical motion of the arytenoids due to inward motion of the weakened arytenoids
 Be prepared to intubate

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 Arytenoid motion can be
reliably detected before
doxapram in approximately
50% of dogs, and that the
other 50% will show
definitive arytenoid motion
after doxapram
administration.
 Neither propofol nor
alfaxalone alone result in
reliable arytenoid motion
either before or after
doxapram
SEDATION PROTOCOLS
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• Acepromazine
• 0.03 mg/kg
• Butorphanol
• 0.2 mg/kg
PreMed
• Alfaxalone
• 2 mg/kg
• Propofol
• 6 ml/kg
Sedation /
Induction
• Doxapram
• 0.25 mg/kg
Respiratory
Stimulant

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 Pre-oxygenate
 +/- Premedication
 Acepromazine 0.01 mg/kg +/- Butorphanol 0.2 mg/kg IV
 Sedation/Induction
 Propofol 6-7 ml/kg IV OR Alfaxalone 2 mg/kg IV
 Respiratory Stimulant
 Doxapram 0.25-1 mg/kg IV = 15-30 seconds of increased respiratory drive
MY CURRENT PLAN
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 Assess pharyngeal structures
 Palate
 Soft palate
 Normal length should NOT interfere
with the movement of the epiglottis
 Pharynx
 Tonsils
 Epiglottis
PHARYNGEAL EXAM
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 Larynx
 Epiglottis
 Arytenoids and vocal folds
LARYNGEAL EXAM
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LARYNGEAL EXAM
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LARYNGEAL EXAM
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DYSPNEIC DOG
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Brachycephalic obstructive airway syndrome
 Synonyms: Brachycephalic airway syndrome / BAS;
 Acronyms: BS, BAS, BOAS, BAOS
UPPER AIRWAY DYSPNEA
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BRACHYCEPHALIC OBSTRUCTIVE AIRWAY SYNDROME
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 “Calvin” Palamara
 3.5 yr MN French Bulldog
 Fall 2018 =
 Cyanosis, exercise intolerance
 Rhinoplasty, Staphylectomy, Sacculectomy

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 2015 AKC
 7 of top 25 breeds are brachycephalic
 #4 Bulldogs
 #6 French bulldogs
 #10 Boxers
 #18 Cavalier King Charles Spaniel
 #19 Shih Tzu
 #21 Pomeranian
 #22 Boston Terrier
WHY IS BRACHYCEPHALIC DISEASE IMPORTANT?
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 UK Kennel Club registrations
 Between 2002 and 2013
 Pug – 730% increase
 French Bulldog – 2,708% increase

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BRACHYCEPHALIC OBSTRUCTIVE AIRWAY SYNDROME (BOAS)
COMMONLY AFFECTED BREEDS
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BRACHYCEPHALIC OBSTRUCTIVE AIRWAY SYNDROME (BOAS)
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 Primary components
 Stenotic nares Macroglossia
 Aberrant nasal / nasopharyngeal turbinates
 Overlong (elongated) soft palate
 Hypoplastic trachea
 Secondary components
 Mucosal edema Everted tonsils
 Everted laryngeal saccules Laryngeal collapse
 Redundant pharyngeal tissue
 Gastrointestinal abnormalities
 Esophageal deviation, GER, hiatal hernia,
esophagitis, pyloric mucosal hyperplasia

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 (1) Nares and Nasal Cavity
 Stenotic nares
 Nasopharyngeal turbinates, incl mucosal contact points
 (2) Palate and Larynx
 Soft palate elongation and hyperplasia
 Everted laryngeal saccules
 Laryngeal collapse
COMPONENTS TO BE DISCUSSED
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 Normal physiology of the nares
 Nose and nasal cavity = contributes ~75% of the total airway resistance during normal
inspiration
 Larynx = ~5% Bronchi and bronchiole = ~20%
 Primary abnormal anatomy – stenotic nares, abnormal nasal turbinates
 Nasal stenosis leads to stertorous breathing (need for increased negative pressure =
increased labored breathing distal to the resistance)
 Build up of negative pressure draws soft tissues into the airway lumen, making them
hyperplastic
 Elongated soft palate projects into the larynx causing stridor
 Excessive, repetitive extreme negative pressure can lead to secondary airway collapse
 Inspiratory and expiratory muscle work generates substantial heat precipitating
hyperthermia and heat stroke
BOAS PATHOPHYSIOLOGY
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 Other disorders:
 Sleep apnea
 Cyanosis and syncope
 Clinical sign onset
 Often severe by 12 months of age
BOAS PATHOPHYSIOLOGY
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UPPER AIRWAY ANATOMY NORMAL VERSUS ABNORMAL
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 Fasanella et al JAVMA 2010. Components of brachycephalic
airway obstructive syndrome (BAOS).
 Retrospective study
 Goal: report the prevalence of BAOS in dogs (without narrow
case selection), incl everted tonsils*
PREVALENCE OF
ANATOMIC COMPONENTS OF BOAS
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PREVALENCE OF BREEDS WITH COMPONENTS OF BOAS
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English
Bulldogs, 62%
Pugs, 21%
Boston Terriers,
9%
Breeds
English Bulldogs Pugs Boston Terriers French Bulldogs Other

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PREVALENCE OF ANATOMIC COMPONENTS OF BOAS
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Elongated Soft Palate, 94%
Stenotic Nares, 77%
Everted Laryngeal Saccules, 66%
Everted Tonsils, 56%
Elongated Soft Palate
Stenotic Nares
Everted Laryngeal Saccules
Everted Tonsils
0% 20% 40% 60% 80% 100%
Components of BAOS
Percentage of Patients

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 Other findings:
 Most patients had 3 or 4 components of BAOS
 Most common combination = stenotic nares, elongated soft palate,
everted laryngeal saccules, everted tonsils
 Comorbidities:
 72% of patients had stenotic nares and everted laryngeal saccules
 66% of patients had everted saccules and everted tonsils
 Corrective surgery post-operative complications = 12% (10/83)
PREVALENCE OF ANATOMIC COMPONENTS OF BOAS
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 Skull Conformation
 Shorter and wider skull = compressed nasal passages and altered pharyngeal anatomy
(1) NARES AND NASAL CAVITY
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 Anatomy
 Normal: Free end of the dorsal
lateral cartilage (thick and
vascular) merges with the rostral
extremity of the ventral nasal
conchae
 Alar folds: bulbous portion of
the ventral nasal conchae
 Brachycephalics: short and thick
alar folds, collapse inward leading
to subsequent stenosis secondary
to cartilaginous or muscular
weakness
NARES
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 Physical exam findings:
 Varying degrees of obstruction of the nasal vestibule
 Surgery is recommended due to development of airway secondary effects
STENOTIC NARES
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4 Severe stenosis 3 Moderate stenosis 2 Mild stenosis 1 Normal

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 Stenotic Nares
 First reported by
Harvey et al JAAHA 1982.
 Rhinoplasty – various techniques
SURGERY: STENOTIC NARES
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Before After

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 Stenotic Nares:
 Rhinoplasty – various techniques
 Trader’s technique
(amputation of the dorsal nasal cartilage)
SURGERY: STENOTIC NARES
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 Stenotic Nares
 Rhinoplasty – various techniques
 Trader’s technique (amputation of the
dorsolateral nasal cartilage)
 Vertical, horizontal or lateral alar fold
wedge resection
 Alapexy (abduction of the ala)
SURGERY: STENOTIC NARES
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 Anatomy
 Nasal concha: dorsal, ventral
 Ethmoidal labyrinth
 Nasal turbinates: ectoturbinates,
endoturbinates
 Nasal meatuses
 Dorsal, middle, ventral, common
 Function
 Humidify and warm inspired air
NASAL TURBINATES
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 Ginn et al JAAHA 2008. Evidence of nasopharyngeal turbinates.
 Retrospective study of brachycephalics undergoing upper airway endoscopy
 Goal: report nasopharyngeal turbinates and its incidence in brachycephalics with signs of
upper respiratory disease
 NP turbinates identified in 21% of brachycephalic animals – 21% of dogs and 20% cats in study
 Pugs accounted for 32% of all dogs in study population; 82% had NP turbinates
NASOPHARYNGEAL TURBINATES
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 Oechtering et al Vet Surg 2016.
 Intranasal anatomy / aberrant turbinates.
 Prospective study of brachycephalics undergoing CT and rhinoscopy
 Goal: document intranasal obstruction in brachycephalics with signs of upper respiratory
disease
 All dogs (132 of 132) had abnormal conchal growth causing intranasal obstruction
ABERRANT NASAL TURBINATES
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 RAT (rostral aberrant turbinates) – 91% of Pugs,
56% French Bulldogs, 36% English Bulldogs
 CAT (caudal aberrant turbinates) – 67% of all breeds
 Nasal septum deviation - consistent finding in Pugs (99%), less common in Bulldogs
 Interconchal and intraconchal mucosal contact points in 91.7% of dogs
 Using impulse oscillometry, intranasal obstruction effect was measured and shown to
cause elevated nasal airway resistance
ABERRANT NASAL TURBINATES
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NASAL CAVITY - CT SCAN
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• Normocephalic (German Shepherd) • Brachycephalic (Pug)
• Nasal cavity comparison
– Extreme reduced size
in Pug
– Endoturbinate malformation
resulting in caudal aberrant
turbinate
• Frontal sinus missing in Pug
• Compare nasopharynx in GSD
and Pug
2019 SUMMER CE | THE DYSPNEIC DOG

74. WWW.UVSONLINE.COM
 p1:
 Nasal septum
deviation in Pug
 p2:
 Nasal conchae
extend caudally
and obstruct the
nasopharynx in Pug
NASAL CAVITY
- CT SCAN
• Normocephalic (German Shepherd) • Brachycephalic (Pug) 6/3/20192019 CE | THE DYSPNEIC DOG2019 SUMMER CE | THE DYSPNEIC DOG

75. WWW.UVSONLINE.COM
 Endoscopy – nasal
vestibule
 RAT = rostral
aberrant turbinate
 RAT causing severe
nasal meatus
obstruction due to
multiple mucosal
contact points
(1) NARES AND NASAL CAVITY
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
• Normocephalic
(German Shepherd)
• Brachycephalic
(French Bulldog)

76. WWW.UVSONLINE.COM
 Endoscopy – nasal vestibule
 Mucosal contact points
 Extensive !
NASAL CAVITY - ENDOSCOPY
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
• Brachycephalic

77. WWW.UVSONLINE.COM
 Endoscopy – retroflex,
nasopharynx
 CAT = caudal aberrant
turbinate
 CAT causing severe
nasopharyngeal/choanae
obstruction
NASAL CAVITY - ENDOSCOPY
• Normocephalic (German Shepherd) • Brachycephalic (Pug)
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

78. WWW.UVSONLINE.COM
 Laser-assisted turbinectomy (LATE)
*Complete removal of the following:
 Turbinectomy of the nasal vestibule
 Turbinectomy of the RAT
 Turbinectomy of the CAT
 Outcome
 Complications
 32.3% hemorrhage
 6 month followup
 Regrowth of turbinates
 15.8% received a second resection
ABERRANT TURBINATES
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79. WWW.UVSONLINE.COM
 Soft Palate
(2) PALATE AND LARYNX
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80. WWW.UVSONLINE.COM
 Most frequently affected breeds: English and French Bulldogs
 Anatomy
 Divides the nasopharynx
and oropharynx
SOFT PALATE
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81. WWW.UVSONLINE.COM
SOFT PALATE NORMAL VERSUS ABNORMAL
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
• Normocephalic (Shepherd) • Brachycephalic (Boxer)

82. WWW.UVSONLINE.COM
 Cause
 Result of chronic upper airway obstruction
 Clinical signs develop when the palate contacts the epiglottis or
extends past the caudal margin of the tonsils
 Clinical signs
 Stridor
 Gagging +/- vomiting
ELONGATED SOFT PALATE
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83. WWW.UVSONLINE.COM
SOFT PALATE
- ABNORMAL
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
VIDEO

84. WWW.UVSONLINE.COM
 Pathologic thickening of the soft palate,
observed concurrently with other components of BOAS
 Quantitation
 CT: allows for precise pharyngeal measurements using transverse slices at multiple
intervals
 Grand et al JSAP 2006
 Positive correlation between the thickness of the soft palate and the severity of
clinical signs
SOFT PALATE ELONGATION AND HYPERPLASIA
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85. WWW.UVSONLINE.COM
 Elongated soft palate:
 Staphylectomy – various techniques
 Sharp cut-and-sew staphylectomy
technique
 Pay particular attention to appose the
mucosa
 Carbon dioxide laser
 Continuous mode @ 5-6 watts
 Bipolar vessel sealing device (Ligasure©)
SURGERY: ELONGATED SOFT PALATE
http://veteriankey.com/wp-content/uploads/2016/08/B0721604226501637_gr2.jpg
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

86. WWW.UVSONLINE.COM
SURGERY: STAPHYLECTOMY
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
• Staphylectomy (soft palate resection)
– Landmarks: tonsillar crypts

87. WWW.UVSONLINE.COM
SURGERY: STAPHYLECTOMY “3 WAYS”
• Cut-and-Sew Technique • Bipolar vessel sealing device (Ligasure©)
• Carbon Dioxide Laser
**COMPLETED SURGERY**
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

88. WWW.UVSONLINE.COM
 Davidson et al JAVMA 2001. Laser staphylectomy.
 Retrospective study of brachycephalics undergoing staphylectomy
 Goal: compare outcomes of laser versus incisional staphylectomy
 Findings
 Laser staphylectomy was significantly faster
 Ease of procedure using laser was advantageous
 14-day outcomes were similar
SURGERY: LASER STAPHYLECTOMY
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

89. WWW.UVSONLINE.COM
SURGERY: STAPHYLECTOMY – BIPOLAR DEVICE
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90. WWW.UVSONLINE.COM
 Cause
 Eversion or enlargement of the palatine tonsils
 Result of chronic upper airway obstruction
 Clinical signs
 Debated as to the degree of
contribution to BOAS
*Removal recommended if feel
contributing to upper airway obstruction
ENLARGED/EVERTED TONSILS
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

91. WWW.UVSONLINE.COM
SURGERY: TONSILLECTOMY
• Surgery:
– Laser tonsillectomy, bipolar vessel sealing device, sharp dissection and Parker-Kerr oversew
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

92. WWW.UVSONLINE.COM
 First described in 1957
 Cause:
 Result of chronic upper airway
obstruction
EVERTED LARYNGEAL SACCULES
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93. WWW.UVSONLINE.COM
 Cantatore et al, ECVS 2010.
 *Outcome of laryngeal saccule resection in brachycephalic dogs
 Prospective study, 9 dogs
 Objective: Investigate whether reduction in airflow turbulence might allow
for spontaneous resolution of saccules (ie resection is not always necessary)
 Procedure: rhinoplasty, staphylectomy, and unilateral laryngeal
sacculectomy (persistent everted saccule on one-side acting as control)
 Results: Spontaneous resolution was uncommon
 One patient with a poor outcome having aberrant proliferation of tissue at the
sacculectomy site
SURGERY: LARYNGEAL SACCULECTOMY
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94. WWW.UVSONLINE.COM
 Surgery
 Laryngeal sacculectomy (also
called ventriculectomy)
 Procedure: long metzenbaum
scissors to resect reductant
laryngeal saccules
SURGERY: SACCULECTOMY
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
Before After

95. WWW.UVSONLINE.COM
LARYNX
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
NORMAL
a = Corniculate process of the arytenoid cartilage
b = Cuneiform process of the arytenoid cartilage
e = Laryngeal ventricles

96. WWW.UVSONLINE.COM
 Development of Laryngeal Collapse:
 Increased airway resistance, increased negative intraglottic luminal
pressure, and increased air velocity associated with the BAOS (Harvey
1989, Lorinson and others 1997).
 Forces displace the rostral laryngeal structures medially with
permanent cartilage deformation (Wykes 1983).
 The net result is the gradual collapse of the rostral laryngeal opening.
LARYNGEAL COLLAPSE
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 Cause:
 Secondary result of chronic upper airway obstruction
 Considered an end-stage disease
 Patients can do well with medical treatment for mild to
moderate forms
 More severe forms require surgery
LARYNGEAL COLLAPSE
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98. WWW.UVSONLINE.COM
LARYNGEAL COLLAPSE
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LARYNGEAL COLLAPSE
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
http://www.vetfolio.com/respiratory/canine-brachycephalic-airway-syndrome-surgical-management
d = Vocal fold
e = Laryngeal
ventricles
 Grade I Laryngeal Collapse
 Eversion of laryngeal saccules

100. WWW.UVSONLINE.COM
 Grade II Laryngeal Collapse
 Medial displacement (collapse) or paradoxical motion
of the cuneiform processes of the arytenoid cartilages
LARYNGEAL COLLAPSE
https://www.dovepress.com/strategies-for-the-management-and-prevention-of-conformation-related-r-peer-reviewed-article-VMRR
b = Cuneiform
process of
the arytenoid
cartilage
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101. WWW.UVSONLINE.COM
LARYNGEAL COLLAPSE
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
NORMAL
a = Corniculate process
of the arytenoid cartilage
b = Cuneiform process
of the arytenoid cartilage
e = Laryngeal ventricles
 Grade III Laryngeal Collapse
 Medial displacement (collapse) or paradoxical motion
of the corniculate processes of the arytenoid cartilages
with loss of the dorsal arch of the rima glottis

102. WWW.UVSONLINE.COM
 Stage I Laryngeal Collapse
 Marked improvement and favorable prognosis
 Saccule resection (sacculectomy), soft palate resection (staphylectomy), nares resection
(rhinoplasty)
 Stages II and III Laryngeal Collapse
 Historic guarded prognosis
 Aryepiglottic fold resection, permanent tracheostomy, euthanasia
 Recent publications
 Left cricoarytenoid lateralization
LARYNGEAL COLLAPSE
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103. WWW.UVSONLINE.COM
 White, JSAP 2011. Surgery of laryngeal collapse with BAOS.
 Retrospective study, 12 dogs [stage II (2/12 dogs) or stage III (10/12)
laryngeal collapse]
 Goal: Report of 12 BAOS dogs with life-threatening laryngeal collapse
managed with left-sided cricoarytenoid lateralization with
thyroarytenoid caudo-lateralization
LARYNGEAL COLLAPSE
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104. WWW.UVSONLINE.COM
 Results
 All patients experienced a progressive deterioration over 6-12
month prior to presentation
 Surgery: all cases received – “cut and sew” staphylectomy, wedge
resection rhinoplasty, left and right laryngeal
sacculectomy…combined with bilateral tonsillectomy (9/12 dogs)
and resection of the glosso-epiglottic fold (4/12 dogs)
 Each cases had continued, severe upper respiratory obstruction
 7/12 dogs: received temporary tracheostomy
 Surgery: left cricoarytenoid lateralization (normal cricoarytenoideus
dorsalis muscle/no atrophy)
 Surgery: arytenoid cartilage was freed and caudally directed
 10/12 had improvement in long-term respiratory function
 2/12 dogs were euthanized due to lack of improvement
SURGERY LARYNGEAL COLLAPSE
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105. WWW.UVSONLINE.COM
 Followup (average, 1.5 years)
 All 10 dogs were alive and none had required
additional surgical intervention for BAOS
 All owners considered that their dogs showed
marked improvement after surgery
(some had rare to occasional mild respiratory
clinical signs )
SURGERY LARYNGEAL COLLAPSE
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106. WWW.UVSONLINE.COM
 Riecks et al JAVMA 2007.
Surgical correction brachycephalic syndrome (BAOS).
 Study: Retrospective study, 62 dogs
 Goal: assess results of surgical correction of brachycephalic
syndrome (including stenotic nares, elongated soft palate, and
everted laryngeal saccules)
SURGERY: OUTCOME, PROGNOSIS, COMPLICATIONS
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107. WWW.UVSONLINE.COM
 Findings:
 Most common breed for all abnormalities = English Bulldog
 Staphylectomy patients had similar outcomes with laser or scissor
resection techniques
 Treatment success rate: 94.2%
 Overall mortality rate: 3.2%
SURGERY: OUTCOME, PROGNOSIS, COMPLICATIONS
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

108. WWW.UVSONLINE.COM
DYSPNEIC DOG
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109. WWW.UVSONLINE.COM
Laryngeal paralysis
 Synonyms: Larpar
UPPER AIRWAY DYSPNEA
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110. WWW.UVSONLINE.COM
LARYNGEAL PARALYSIS
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG
 “AJ” Palamara
 13 yr MN Mountain Dog X
 Spring 2016 =
 Progressive stridor
 Unilateral cricoarytenoid lateralization

111. WWW.UVSONLINE.COM
 Larynx
 Opening of the trachea
 Suspended ventrally by the
hyoid apparatus (e)
 Components of the larynx
 Epiglottis, thyroid, cricoid,
sesamoid, interarytenoid, and
paired arytenoid cartilages
LARYNGEAL FUNCTION
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112. WWW.UVSONLINE.COM
 Cricoarytenoideus dorsalis muscle
 Abductor of the arytenoid cartilage,
opening the glottis
 Origin: cricoid cartilage
 Insertion: the muscular process
 Recurrent laryngeal nerve
 Innervates the Cricoarytenoideus
dorsalis muscle
LARYNGEAL FUNCTION
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

113. WWW.UVSONLINE.COM
 Medulla -> Vagus nerve -> Recurrent laryngeal nerves ->
Caudal laryngeal nerves -> Laryngeal muscle innervation
 Disruption of this pathway results in Laryngeal Paralysis
LARYNGEAL PARALYSIS
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114. WWW.UVSONLINE.COM
 Clinical signs
 Chronic progressive stridor, voice (phonation) changes,
gagging/coughing, exercise intolerance, respiratory distress
 Diagnosis
 Upper airway examination – unilateral or bilateral paralysis,
paradoxical movement (inward movement on inspiration)
 Electromyography [EMG] – dogs as young as 12 weeks
LARYNGEAL PARALYSIS
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

115. WWW.UVSONLINE.COM
 (1) Congenital Laryngeal Paralysis
 Bouvier des Flandres, Bull Terriers, Dalmatians, Rottweilers Pyrenean
Mountain Dogs, Huskies, Malamute, etc
 Autosomal recessive, progressive, guarded to poor prognosis
 Siberian Huskies, Husky crosses, Bouviers
 Progressive degeneration of neurons (nucleus ambiguus) with subsequent
Wallerian degeneration of the laryngeal nerves
 Onset: < 1 year of age
LARYNGEAL PARALYSIS
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116. WWW.UVSONLINE.COM
 Von Pfeil et al JAVMA 2018.
 Breed: Alaskan Huskies
 Phenotype: Blue eyes, white markings, and
oral mucosal tags or tissue bands
 Mean age, onset clinical signs: ~ 6 months
 Mononeuropathy of the recurrent laryngeal nerve
only
 Treatment: cricoarytenoid lateralization
 Prognosis: good to excellent
CONGENITAL LARYNGEAL PARALYSIS
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117. WWW.UVSONLINE.COM
 (2) Acquired Laryngeal Paralysis
 Labradors and Golden Retrievers,
Saint Bernards, and Irish Setters
 Median age – 9 years
LARYNGEAL PARALYSIS
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

118. WWW.UVSONLINE.COM
 (2) Acquired Laryngeal Paralysis
 Conditions: chronic endocrine (hypothyroidism), infectious, or immune-
mediated polyneuropathy, trauma/cervical, idiopathic polyneuropathy
 Generalized idiopathic polyneuropathy
 GOLPP – geriatric onset laryngeal paralysis polyneuropathy
 Generalized neuromuscular weakness
 Esophageal dysfunction – 11% of cases; may require esophagram to diagnosis
 Megaesophagus
LARYNGEAL PARALYSIS
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119. WWW.UVSONLINE.COM
 Jeffrey et al. 2006.
 Goal: Determined the prevalence of clinical and electrodiagnostic evidence
of a more generalized neurological dysfunction in dogs presented with
idiopathic acquired laryngeal paralysis
 Features: Many dogs continuing to exhibit weakness and exercise tolerance
past tieback surgery.
 Findings: Clinical neurological deficits and/or electrodiagnostic
abnormalities were found in each case. There was limited evidence that
specific neurological deficits were associated with a poor prognosis for full
recovery of exercise tolerance
GERIATRIC ONSET LARYNGEAL PARALYSIS
POLYNEUROPATHY
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120. WWW.UVSONLINE.COM
 Stanley et al. 2010.
 Objectives: To compare esophageal function in dogs with idiopathic
laryngeal paralysis (ILP) to age and breed matched controls; to determine if
dysfunction is associated with aspiration pneumonia over 1 year; and to
compare clinical neurologic examination of dogs with ILP at enrollment and
at 1 year.
 Study: Prospective, 32 dogs; tieback surgery, followed out over 1 year
 Conclusions: Dogs with ILP also have esophageal dysfunction. Postoperative
aspiration pneumonia is more likely in dogs with higher esophagram scores.
Dogs with ILP will most likely develop generalized neuropathy over the
course of 1 year
GERIATRIC ONSET LARYNGEAL PARALYSIS
POLYNEUROPATHY
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121. WWW.UVSONLINE.COM
 Summary:
 Subset of dogs with generalized progressive polyneuropathy
 Esophageal dysfunction – greater risk for aspiration
pneumonia
 Poor prognosis for return to normal activity
 *Educate owners or consider neurology referral if concerns
GERIATRIC ONSET LARYNGEAL PARALYSIS
POLYNEUROPATHY
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122. WWW.UVSONLINE.COM
 Specialty consult – Surgery +/- Neurology
 Bloodwork, thyroid
 Thoracic radiographs
 Upper airway exam
LARYNGEAL PARALYSIS – WORK UP
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123. WWW.UVSONLINE.COM
 Gold standard = (“tieback”)
Unilateral cricoarytenoid lateralization
 Consistent outcomes
 Goal = create a permanent increase in
diameter (one-sided) of the rima glottis
CRICOARYTENOID LATERALIZATION – TREATMENT
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124. WWW.UVSONLINE.COM
 Complications
 Aspiration pneumonia – reported as high as
20% lifelong
 Laryngeal distortion – increased risks
 Seroma
 Persistent cough or gagging
 Failure – suture breakage, cartilage
fragmentation
 Progression of neurologic signs
CRICOARYTENOID LATERALIZATION – TREATMENT
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125. WWW.UVSONLINE.COM
 Improvement expected in 90% of cases
 70% are still alive 5 years after surgery
 Dogs with generalized polyneuropathy at presentation
 ALL developed progressive neurologic signs more than 1 year post-surgery
CRICOARYTENOID LATERALIZATION - PROGNOSIS
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126. WWW.UVSONLINE.COM
 CONCLUSION:
Our inductive and battery-powered prototypes performed effectively during
in vivo testing, and the 2 units that were implanted for long-term evaluation
held up well. As a proof of concept, we demonstrated that elicited neck strap
muscle or laryngeal EMG potentials could be used as a control signal for
closed-loop stimulation of laryngeal adduction and vocal pitch modulation,
depending on electrode positioning, and that VFs were stimulable in the
presence of synkinetic reinnervation or chronic denervation.
FUTURE OF LARYNGEAL PARALYSIS
TREATMENT
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127. WWW.UVSONLINE.COM
 Brachycephalic obstructive airway syndrome & Laryngeal Paralysis
 Anatomic and physiologic abnormal airway function
 Clinical signs of upper airway obstruction
 Clinical signs typically chronic (median, 49 days) with acute exacerbation
 Additional comorbidities – Esophageal / gastrointestinal abnormalities
 *Laryngeal paralysis - polyneuropathy
SUMMARY – UPPER AIRWAY DISEASE
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128. WWW.UVSONLINE.COM
 Brachycephalic obstructive airway syndrome & Laryngeal Paralysis
 Animals presenting with acute cyanosis or collapse
 Medical stabilization
 Determine anatomic origin of respiratory distress
 Determine any comorbidities
 Surgical treatment
SUMMARY – UPPER AIRWAY DISEASE
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129. WWW.UVSONLINE.COM
 Brachycephalic obstructive airway syndrome & Laryngeal Paralysis
 Surgery offers improvement in quality of life and improves or resolves
respiratory signs
 Considered salvage procedures as abnormalities are not completely
resolved
 Prognosis – Good
SUMMARY – UPPER AIRWAY DISEASE
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 Brachycephalic obstructive airway syndrome & Laryngeal Paralysis
 Recommendations
 1) BE MINDFUL of high ambient temperatures and humidity
 Walk early morning OR late day
 Avoid exercise with increased heat index OR humidity
 2) Air conditioning
 3) BE MINDFUL that excitement, anxiety, tachypnea, and hyperthermia
can lead to progressive and severe dyspnea, cyanosis and collapse
SUMMARY – UPPER AIRWAY DISEASE
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131. WWW.UVSONLINE.COM
 Joseph Palamara, DVM, DACVS-SA
 Jpalamara@uvsonline.com
 Tuesday - Friday
 Maxwell Bush, VMD, DACVS-SA
 Mbush@uvsonline.com
 Monday – Thursday
 Michele Litterio – Surgery Liaison
UVS SURGERY
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132. WWW.UVSONLINE.COM
 Minimally-invasive surgery
 Orthopedic surgery
 Soft tissue surgery
 Surgical oncology
 Questions? – call or email
SURGERY DEPARTMENT
6/3/20192019 SUMMER CE | THE DYSPNEIC DOG

133. WWW.UVSONLINE.COM6/3/20192019 SUMMER CE | THE DYSPNEIC DOG