Professional Documents
Culture Documents
10 October 2000
Upper Airway
FOCAL POINT Obstruction in Cats:
★ A thorough understanding of
feline upper airway obstructive
diseases and possible therapeutic
Diagnosis and
alternatives allows diagnosis and
treatment under the same
anesthetic episode, thereby
Treatment*
improving outcome.
University of Edinburgh
■ Flexible endoscopy is valuable ABSTRACT: Clinical signs of upper airway obstruction provide valuable information regarding
for evaluating the choanae, the degree of airway compromise and the anatomic compartment involved but are not specific
nasopharynx, and subepiglottic to any disease process. The purpose of the diagnostic workup is to determine the extent and
areas. nature of the condition. The extent of the physical examination depends on the degree of up-
per airway obstruction, and complete evaluation may need to be postponed until the patient is
■ Middle-ear evaluation is part of anesthetized. However, rapid assessment of respiratory impairment is crucial because it al-
lows appropriate triage of patients. In cats with mild upper airway obstruction, radiographs of
the diagnostic approach for
the thoracic and cervical areas may be obtained with the patient either awake or under seda-
nasopharyngeal polyps.
tion. A complete oral and laryngeal examination should be performed with the patient under
anesthesia. Additional tests may also be indicated. Manipulation of the upper airway in a com-
■ Nasopharyngeal stenosis is easy promised patient is likely to exacerbate signs; therefore, diagnostic tests and corrective
to diagnose and carries a good surgery should be scheduled under the same anesthetic episode. This article describes the
prognosis after surgery. corrective surgical techniques for obstructive airway diseases. Although these techniques may
be technically demanding, they do not require specialized equipment and, depending on the
■ Treatment of granulomatous nature of the disease, often provide good results.
laryngitis consists of surgery and
long-term antiinflammatory
C
therapy. linical signs of upper airway obstruction are variable and not specific to
any disease process. Signs may help to localize disease, but a thorough di-
■ Unilateral arytenoid lateralization agnostic approach is needed to diagnose the condition. The severity of
provides excellent results in cats signs will depend on the degree of functional obstruction and will dictate the
with permanent laryngeal initial therapeutic approach. On presentation, triage should be conducted im-
paralysis. mediately so that patient care can be prioritized accordingly. Cats with severe
upper airway obstruction should be anesthetized and intubated as quickly as
possible.1 Placement of a cricothyrotomy tube or emergency tracheostomy
should be limited to patients that cannot be intubated and that require bypass of
the larynx.
Diagnostic evaluation should be performed after respiratory function has im-
*A companion article entitled “Upper Airway Obstruction in Cats: Pathogenesis and
Clinical Signs” appeared in the September 2000 (Vol. 22 No. 9) issue of Compendium.
Small Animal/Exotics Compendium October 2000
COMPENDIUM
ON CONTINUING EDUCATION
scopically. Tracheoscopy will also improve visualization ®
F O R T H E P R A C T I C I N G V E T E R I N A R I A N
of subepiglottic tumors and facilitate biopsy.
Veterinary Technician reprints also available
Histopathology
Histologically, nasopharyngeal polyps consist of a 2001 PRICE SCHEDULE*
core of well-vascularized fibrous connective tissue cov- 2 4 8 12 16
ered by stratified squamous or columnar epithelium.9 Quantity pages pages pages pages pages
Inflammatory cells are especially prominent in the sub- Black & White
mucosa.10 However, a presumptive diagnosis of na- 100 $ 108 $ 204 $ 416 $ 604 $ 784
500 152 296 616 896 1,156
sopharyngeal polyp can usually be made on the basis of 1000 208 412 868 1,260 1,628
signalment, history, and the appearance of the mass. 5000 636 1,264 2,828 4,076 5,160
Preoperative biopsy is, therefore, not essential. Instead, 10,000 1,172 2,332 5,280 7,596 9,572
I recommend immediate surgical treatment and histo- Color
pathology of the excised tissue. Similarly, the gross ap- 100 $ 972 $1,408 $2,856 $4,180 $5,380
500 1,152 1,612 3,112 4,704 6,040
pearance of nasopharyngeal stenosis and abscesses is char- 1000 1,264 1,840 3,428 5,260 6,852
acteristic. 5000 2,328 3,600 7,140 10,672 12,168
Making a diagnosis of laryngeal masses requires 10,000 3,280 5,792 10,640 16,704 18,812
histopathology. Granulomatous laryngitis must be dif- *Price includes UPS Ground Shipping to one location.
the mass as well as the organ involved.14 Ultrasonography Detach and Mail to: Reprints Department
may be easier than is radiography to perform on sedated Veterinary Learning Systems
patients and may provide useful preoperative informa- 275 Phillips Boulevard
tion. Assessing the degree of vascularization and invasive- Trenton, NJ 08618
No telephone calls accepted.
ness of cervical masses will help in planning surgical
MACROPHAGES ■ TRACHEOSTOMY
Compendium October 2000 Small Animal/Exotics
Produce the ultimate
treatment and in anticipating complications. The ultra-
sonographic appearance of a laryngeal cyst has recently
in dental x-rays
been reported in a cat.15 Ultrasonographic evaluation
performed without sedation provided a preoperative
Atlas of Canine & Feline
diagnosis. Alternatively, cysts may be diagnosed by fine-
needle aspiration during laryngoscopic examination. Sur-
DENTAL RADIOGRAPHY
gical treatment may be performed under the same anes- Thomas W. Mulligan • Mary Suzanne Aller •
thetic episode. Charles A. Williams
Computed tomography helps delineate the extent of Mary Suzanne Aller, Editor
nasal and nasopharyngeal tumors and may be used to
evaluate middle-ear disease in cats with nasopharyngeal 248 pages, 846 radiographs with arrow
polyps.4,5 Electromyography and muscle biopsies are not overlays to indicate notable features
needed to diagnose laryngeal paralysis. They may, how-
ever, be indicated to evaluate other muscle groups in
cats with suspected generalized neuropathy.
TREATMENT
Nasopharyngeal Polyps
The timing of surgery and the techniques used will
depend on clinical presentation and the extent of dis-
ease. A ventral bulla osteotomy is indicated when evi-
dence of middle-ear disease is found. This may be per- RATED
formed first to remove all attachments of the polyp. ★★★★★
The septum dividing the bulla into a small ventromedi-
al and a large dorsolateral compartment must be re-
moved. 16 Care should be taken when curetting the
promontory to avoid damage to sympathetic fibers and
subsequent postoperative Horner’s syndrome.17 Cul-
$
80
tures can be obtained from the bulla during surgery,
and excised tissue can be submitted for histopathology.
$89
Secondary bacterial infection should be anticipated and
% off! First in the field
a broad-spectrum antibiotic administered intravenously
(e.g., cephazolin, 20 mg/kg). When a bacterium is iso-
0
1 846 reference radiographs
lated, postoperative antibiotherapy should be adjusted
according to sensitivity and continued for 3 weeks. A ■ Practical tips throughout
Penrose drain or a modified butterfly catheter connect- ■ More than 840 real-case images with indicative
ed to a vacutainer tube18 may be placed before closure arrows
of the surgical site to provide drainage and minimize ■ State-of-the-art techniques for the beginning
postoperative swelling. Primary closure has been found practitioner, technician, and specialist
to be as successful as is passive drainage after total ear
■ Precise information on positioning, supplies
canal ablation and lateral bulla osteotomy in dogs.19 Al-
and equipment, processing, safety, film
though no similar study has been performed in cats
with ventral bulla osteotomy, primary closure is an ac- handling, and more
ceptable option.
If a bulla osteotomy is not indicated, traction avul-
sion is used to remove polyps from the ear canal and/or
nasopharynx. A ventral midline approach through the VLS
VE T E R I N A RY
BOOKS
L E A R N I NG SYS T E M S
soft palate may be required if the nasopharyngeal polyp
cannot be retracted caudally (Figure 1).
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Nasopharyngeal Stenosis 800-426-9119 • Fax: 800-556-3288
Nasopharyngeal stenosis can be treated by resecting
Price valid only in the US, Canada, Mexico, and
the membrane covering the internal nares; however, web- the Caribbean. Request international pricing.
Email: books.vls@medimedia.com
Your comprehensive
brought in apposition with the incised mucosa at the lev-
el of the tracheal lumen. guide to diagnostic
Laryngeal Paralysis ultrasonography
Cats with cervical swelling resulting from trauma,
surgery, or neoplasia of adjacent structures may present Nautrup and Tobias
with neurapraxia of the recurrent laryngeal nerve. In
these cases, laryngeal paralysis can be temporary and sup-
portive treatment may be considered.32,33 Oxygen therapy
and temporary tracheostomy in combination with an an-
tiinflammatory dose of short-acting corticosteroids (e.g.,
dexamethasone sodium phosphate, 0.25 mg/kg twice/
day) are often required. This treatment should be discon-
tinued (within a week) after the swelling has decreased or
if the tracheostomy tube becomes nonfunctional. Cats
tend to produce more mucus than do dogs31 and I have
found maintenance of tracheostomy tubes beyond 3 days
difficult. If palliative treatment becomes impractical be-
fore laryngeal function is recovered, definitive repair is
recommended.
The three surgical procedures most commonly de- New
scribed for the treatment of laryngeal paralysis in dogs
include castellated laryngofissure, ventriculocordectomy
and partial arytenoidectomy, and unilateral or bilateral
arytenoid lateralization.34–36 Castellated laryngofissure is
technically demanding in dogs, and would be even more
so in cats, in which the thyroid cartilage may be too
small to create an adequate central cartilaginous flap.
$
149
Robert E. Cartee, Editor
Partial laryngectomy and vocal fold removal by an oral
approach has been used successfully in a few cats with la-
400 pages, hard cover
ryngeal paralysis.37–39 Although relatively simple, this 1597 illustrations
technique requires placement of a temporary tracheosto-
my tube37; complications, including postoperative ede- ■ Sonographic diagnosis in dogs and cats,
ma, aspiration, and laryngeal stenosis, are well recog- including ultrasound, M-mode, pulsed
nized in dogs.26,35,37
and color Doppler echography
Although unilateral arytenoid lateralization is techni-
cally more demanding, I prefer the procedure described ■ Echocardiography, abdominal and pelvic
by Lahue34 for treating cats with permanent laryngeal sonography, and fetal ultrasonography
paralysis. Unilateral arytenoid lateralization has previ-
ously been described in cats.40,41 Mobilization of the ■ Case illustrations using conventional
arytenoid cartilages seems subjectively easier in cats radiography, computed microfocal
than in dogs, possibly because cats lack an interary-
tomography, specimen photography,
tenoid cartilage. Transection of the interarytenoid liga-
ment is not warranted. Two 3-0 polypropylene sutures and line drawings
should be placed through the dorsocaudal edge of the ■ Recognition of the disease process and
cricoid. Alternatively, sutures may be placed through
the caudal cornu of the thyroid cartilage. In canine ca- courses of treatment
daver larynges, however, cricoarytenoid lateralization
techniques provided a greater increase in the size of the
glottic opening than did thyroid lateralization tech- CALL OR FAX TODAY TO ORDER
niques.40 Each suture passes under the caudal laryngeal 800-426-9119 • Fax: 800-556-3288
nerve and through the cricoarytenoid articular surface
Price valid only in the US, Canada, Mexico, and
or the muscular process of the arytenoid cartilage. The
the Caribbean. Request international pricing.
Email: books.vls@medimedia.com
Figure 6A
rn on a Rat Po
isoning
Unexpected Tu
clining latex cryptococcal antigen agglutination titers. DIAGNOSTIC CHALLENGE By Marjory
Brooks, D.V.M
and Jeff Jacobs
on, D.V.M
.
., Dipl. A.C.V.
I.M.,
of apomorphine
treatment consiste
and 30 mL of
d of subconjunctiva
oral hydrogen
therapy, Mugsy
peroxide to induce
vomited a large
SEALING ry
NS BY LES
blood chemist
nation. All
ILLUSTRATIO
treatment in cats, probably because of their sedentary na- A recheck examina vitamin K regimen to
confirm , an unexpec K deficiency
was 65.9 seconds al PT due to vitamin
ion of the owners report- initiating an
after complet Although his rection of abnorm 48 hours of
coagulopathy. and Mugsy within 24 to
resolution of K1 as directed should resolve K1. of
had given vitamin re to rat poison, clotting appropriate
dose of vitamin persistent prolongation
ed that they for reexposu y the cause of vitamin
nity was markedl To determi ne al
had no opportu time (PT) assay whether addition for more
prothrombin finding in the PT and
time in the : 9.5-12.5). This clotting time a sample was
sent
ture. The surgical correction of stenotic nares involves re- through the steps leading to the 57 seconds (normal d that his early pre- was needed, was drawn
prolonged at it appeare K therapy . Whole blood
ted because prevented ion analyses 3.8 percent
was unexpec vomiting had detailed coagulat anticoagulant (one part
productive Contrac, how- citrate ged, and the
sentation with of rodenticide. directly into and centrifu
a toxic dose poison. parts blood) cold packs to
a vet-
absorption of iolone, a long-acting K citrate to nine was shipped on tion
s bromad vitamin 1 plasma Coagula
ever, contain at the same supernatant (Comparative
therefore resumed e laboratory University,
Treatment was erinary referenc ory, Cornell
words. 76 Veterinary
Forum
KAREN WILSON
Intussuscep
mouth44 to dislodge secretions accumulated in the lar- While the course of therapy is of- tio
In a Yearlin n
g
ynx and provoke a swallowing reflex, thus interrupting ten clear-cut, some patients pre-
By Linnea Lentz,
D.V.M.
B
the spasm. A short-term course of an antiinflammatory sent true challenges to medical
eau, a 15-mont
when the owners
described as mild,
nixine) administe
h-old colt, had been
called the referring
and Beau was treated
red intravenously
colicky for about
veterinarian. The
four hours
with 10 cc Banamin ®
colic was
e (flu-
and no other
ties. An initial
abnormali-
IV injection
of xylazine appeared
scribed as a large, cystic mass located in the cervical re- Canine Hemipares
is , D.V.M.
pharyngeal plexiform vasculopathy was cured after exci- signs. Word count: 1000-2000. 66 Veterinary Forum
Peer Reviewed
August 2000
CONCLUSION
An initial evaluation of cats with upper airway ob-
struction should be used to assess the degree of respira- SEND YOUR ARTICLES TO:
tory impairment and allow appropriate triage. A good
Editor, Veterinary Forum
understanding of the epidemiology and pathophysiolo-
gy of upper respiratory obstructive disease in cats allows 275 Phillips Blvd.
clinicians to establish and prioritize a list of differentials. Trenton, NJ 08618
However, the selection, timing, and sequence of diag-
Fax: (609) 882-6357
nostic tests also depend on the severity of airway com-
promise and the personality of the cat. E-mail: lmiller.vls@medimedia.com
After the nature, location, and extent of the disease 19. Devitt CM, Seim HB, Willer R, et al: Passive drainage ver-
have been identified, treatment options and prognosis sus primary closure after total ear canal ablation-lateral bulla
osteotomy in dogs: 59 dogs (1985–1995). Vet Surg 26(3):
can be discussed. When possible, diagnostic tests and 210–216.
corrective surgery should be performed during the same 20. Coolman BR, Marretta SM, McKiernan BC, et al: Choanal
anesthetic episode to facilitate recovery. Some diseases atresia and secondary nasopharyngeal stenosis in a dog. JAAHA
(i.e., nasopharyngeal stenosis, abscesses and cryptococ- 34(16):497–501, 1998.
21. Novo RE, Kramek B: Surgical repair of nasopharyngeal
cosis, laryngeal cysts, granulomatous laryngitis) are un- stenosis in a cat using a stent. JAAHA 35:251–256, 1999.
usual but carry a good to excellent prognosis if recog- 22. Brown OE, Pownell P, Manning SC: Choanal atresia: A
nized early and treated appropriately. When surgery is new anatomic classification and clinical management appli-
indicated, successful outcome will depend on appropri- cations. Laryngoscope 106:97–101, 1996.
23. Harvey CE, O’Brien JA: Surgical treatment of miscellaneous
ate surgical technique as well as anticipation of potential laryngeal conditions in dogs and cats. JAAHA 18:557–562,
complications and postoperative monitoring. 1982.
24. Oakes MG, McCarthy RJ: What is your diagnosis? Granulo-
matous laryngitis in a dog. JAVMA 204:1891–1892, 1994.
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43. Malik R, Martin P, Church DB, et al: Nasopharyngeal cryp- About the Author
tococcosis. Aust Vet J 75(7):483–488, 1997. Dr. Griffon is affiliated with the Department of Small Ani-
44. Levy JK, Ford RB: Diseases of the upper respiratory tract, in mal Surgery, Hospital for Small Animals, University of Ed-
Sherding RG (ed): The Cat. Diseases and Clinical Manage- inburgh, United Kingdom. She is a Diplomate of the Amer-
ment, ed 2. New York, Churchill Livingstone, 1994, pp
947–978. ican College of Veterinary Surgeons and the European
45. Caywood D, Wallace LJ, Alsaker RD, et al: A laryngeal cyst College of Veterinary Surgeons.
in a dog: A case report. JAAHA 13(1):87–91, 1977.