Managing upper airway disease (Proceedings)
Upper airway diseases/obstruction are relatively common causes of respiratory distress in dogs and cats. However, because lung parenchymal diseases are more frequently observed, upper airway problems may be overlooked. In order to fully appreciate upper airway disease, it is essential to be familiar with the structure, function, and common abnormalities.
The upper airway begins with the mouth, nose and pharynx. The principal role of these structures is the conduction of air. Additionally, they also serve to filter larger particle debris from the inspired air. Respiratory problems related to the pharynx generally reflect obstruction to airflow and are characterized by inspiratory distress. Common causes of pharyngeal airflow obstruction include brachycephalic airway syndrome (excessive soft tissues of the pharynx and elongated soft palate), abscesses (from penetrating objects like sticks), mucoceles and neoplasia (lymphoma or metastatic diseases). In young cats, nasopharyngeal polyps may also cause airway obstruction. Diagnosis is based upon visual examination ± biopsy. Therapy for pharyngeal diseases usually involve weight loss (for excessive tissues) or surgical intervention (elongated soft palate / nasopharygneal polyps/mucoceles etc).Larynx
Laryngeal diseases are fairly common in small animals. The function of the larynx is to permit the flow of air into the lungs and also to guard the airway against aspiration of foods or liquids. The larynx is responsible for a large portion of the airflow resistance in the upper airway. Additionally, the larynx is responsible for vocalization. The neuromuscular control of the larynx is through the recurrent laryngeal nerve for the abductors (dorsal cricoarytenoideus is the most important) and the cranial laryngeal nerve (for the abductors). Clinical signs of laryngeal disease include noisy breathing, stridorous breathing, increased inspiratory effort, coughing and voice change. Signs may develop over time or may appear to develop acutely. Clinical signs are usually pronounced with exercise and may correspond with the first hot and humid days of summer. Auscultation over the larynx will reveal loud sounds, which may be referred into the thorax. The most common laryngeal problem in dogs is laryngeal paralysis. Laryngeal paralysis may be congenital (eg. Bouviers, Siberian Huskies, Rottweilers, Dalmatians) but is much more frequently acquired in large breed dogs. Commonly observed breeds of dogs include the Labrador retriever and setters although any breed may be affected. The cause is generally not identified. (Idiopathic) Hypothyroidism was historically thought to be associated with the development of laryngeal paralysis but this is no longer considered true. Rarely, afflicted dogs will have other signs of a polyneuropathy (megaesophagus, generalized muscle weakness). In contrast to horses, clinical signs in dogs are usually associated with bilateral paralysis. In brachycephalic breeds (eg. Bulldog) laryngeal collapse may also occur. Other laryngeal diseases observed in dogs include webbing (after debarking surgery) neoplasia (squamous cell carcinoma, lymphoma etc) or abscess/granuloma (infectious). Everted laryngeal saccules (lateral ventricles) may develop secondarily to upper airway obstructions (and resultant translaryngeal pressure changes). Over time, these saccules may become fibrotic and contribute to permanent airway obstruction.
In cats, laryngeal diseases are much less common. Clinical signs in cats are similar to those observed in dogs. Rarely, cats with significant volume pleural effusions may appear to have upper airway obstruction. Laryngeal paralysis in the cat is frequently associated with neoplasia or may develop after neck surgeries (thyroidectomies). In cats, unilateral paralysis seems more likely to cause clinical signs. Cats may also develop laryngeal tumors (SCC, lymphoma) or granulomas.
Diagnosis of laryngeal disease is based upon direct visualization of the larynx under light sedation. Commonly used agents include thiopental (5-15 mg/kg) or propofol (2-6 mg/kg). Anesthetic agents such as ketamine or oxymorphone may affect the interpretation of the laryngeal motion so should be avoided. In evaluation of the laryngeal function, it is important to 1) have an assistant announce the timing of the respiratory cycle ("In" "Out" etc) 2) Be patient if the animal is too deep as this can lead to over-interpretation of laryngeal dysfunction. Doxapram (Dopram©) (2.2 mg/kg iv) may be given for the respiratory stimulation in order to better evaluate function. 3) Be comfortable with the normal anatomy (Even experienced clinicians may not be comfortable with normals despite intubating numerous dogs and cats) For evaluation of anatomy, the animal may be under deeper anesthesia. It is also prudent to have a plan of action after the laryngeal examination is complete. For example, in our hospital, we will often go straight into surgery following an upper airway examination or are prepared to perform a biopsy if a mass is identified. Additionally, if a "difficult' airway is suspected, it is wise to have several options available for providing supplemental oxygen and supplies for the emergent tracheostomy.
Therapy of laryngeal diseases depends upon the condition. Some conditions may be managed medically with mild sedation (acepromazine), anti-inflammatory agents (glucocorticoids) and weight loss (if indicated). Other conditions require surgical interventions. Laryngeal masses may be debulked with surgery and then further therapy such as chemotherapy or radiation therapy may be pursued as directed by biopsy results. Severe laryngeal paralysis is usually managed through surgery. Surgical options include arytenoid lateralization ("tie-back") or partial laryngectomy. The surgical technique chosen is typically dependent on surgeon preference, although many individuals advocate the lateralization technique. Laser technology may also be employed. Temporary tracheostomy may be required for short-term management of the animal with severe upper airway obstruction. Cats may also be managed with a temporary tracheostomy although due to the smaller lumen of their trachea it may be more difficult to maintain a patent tube. Permanent tracheostomy may be indicted in animals with severe upper airway obstruction that is non-responsive to standard medical or surgical therapy. Permanent tracheostomy requires a dedicated owner, similar to other conditions that require daily therapy.