ULTRASONOGRAPHIC EXAMINATION OF THE PHARYNX AND LARYNX OF

THE NORMAL DOG

BA, VETMB,MRCVS,
P. BRAY,MVSc, CERTSAS,MACVSc, MRCVS, VICKYJ. LIPSCOMBE,
JONATHAN
RICHARD
A.S. WHITE,BVETMED,PHD,DSAS, DVR, FRCVS, HEIKERUDORF,
DR.MED.VET.,
DVR, MRCVS

Real-time ultrasonographic examination of the canine larynx was performed in 12 normal dogs using
a 7.5-mHz mechanical sector scanner combined with a stand-off. A variety of breeds and ages were
examined. All examinations were performed in nonsedated, conscious animals. Transverse scans were
found to provide the most reliable and interpretable images. Identification of laryngeal structures
included the epiglottis, laryngeal and cricoid cartilages, and the vocal cords. In conscious animals,
abduction and adduction of the vocal cords associated with respiration could be identified if the animal
was made to pant during the examination. Movement of the vocal cords could also be quantified by
pulse-wave Doppler recording. In all animals, recordings were made during inspiration only, with
muscular vibration at a rate less than 0.1 m/s. Veterinary Radiology & Ultrasound, Vol. 39, No. 6, 1998,
p p 566-571.

Key words: ultrasound, canine, dog, larynx, laryngeal paralysis, respiratory movement, pulse-wave
Doppler, vocal cords.

Introduction
D ISEASE AFFECTING THE canine larynx is often suspected
following clinical examination of the exercise intoler-
ant or dyspneic animal.’” Diagnosis of laryngeal disease
currently relies on direct visual assessment in the lightly
anesthetized patient, a technique known as laryngoscopy.
Additional techniques used in the investigation of laryngeal
dysfunction include nerve conduction ~ t u d i e shistopathol-
,~
ogy,536histo~hemistry,~,~ tidal flow breathing loops:,8 and
blood gas analysis.’ Radiography of the larynx is rarely
diagnostic for functional lesions, but a lateral view may
reveal structural abnormalities (e.g., radiopaque foreign
bodies, mass lesions, cartilage fractures, or displacement of
the larynx or hyoid bones).”
Laryngoscopy permits thorough inspection of pharyngeal
and laryngeal structures and enables observation of laryn-
geal movements. 1-3 However, anesthesia disrupts normal
muscular activity of the larynx; therefore, accurate assess-
ment of laryngeal function becomes In addition,
recovery from anesthesia might pose a risk in animals suf-
fering from laryngeal dysfunction or obstruction.
The normal ultrasonographic description of the infant hu-
From The Queen’s Veterinary School Hospital, Department of Clinical
Veterinary Medicine, University of Cambridge.
Address correspondence and reprint requests to J.P. Bray, MVSc, Centre
for Companion Animal Health, IVABS, Massey University, Palmerston
North, New Zealand.
Received December 30, 1996; accepted for publication December 10,
1997.
man larynx was first reported in 1990,’’ and this was fol-
lowed by clinical reports of the ultrasonographic detection
’
of laryngeal neoplasia” and paralysis’3-’ in pediatric hu-
man patients. These reports provided descriptions of the
normal ultrasonographic appearance of the tongue, epiglot-
tis, laryngeal cartilages, and vocal cords. Investigators claim
that ultrasonography is superior to other diagnostic modali-
ties, because imaging is performed in real time, and move-
ments of the laryngeal cartilages and vocal cords during
respiration are clearly visible.I2 These movements can be
accentuated by encouraging the patient to inhale deeply dur-
ing the scan, which causes maximal laryngeal adduction.
Laryngeal ultrasonography remains to be investigated in
the dog. On the basis of previous human reports, this mo-
dality has potential value for diagnosis of laryngeal condi-
tions in the dog, including laryngeal paralysis, laryngeal
neoplasia, and laryngeal collapse. This investigation de-
scribes the normal ultrasonographic appearance of the ca-
nine pharynx and larynx. Attention is also given to whether
ultrasound examination enabled laryngeal movements asso-
ciated with respiration to be identified and measured objec-
tively.
Materials and Methods
This study was performed on 12 normal dogs that were
clinically healthy and free of respiratory disease. A variety
of breeds were examined, including the Greyhound (3),
Bedlington terrier ( 3 ) , Labrador (2), Golden retriever (l),
Springer spaniel (l),Cavalier King Charles spaniel (1) and
Curly coated retriever (1). The dogs were between 3 and 10
years of age.

566
VOL. 39. No. 6
For the ultrasound examination, the animals either sat or
lay in sternal recumbency on a table. The dogs were gently
restrained with the neck held in slight extension. Hair was
clipped from the ventral neck from the midmandibular to
midcervical region. An ultrasound machine* with a 7.5-
mHz mechanical sector scanning transducer, 6-mm short
focus plus a stand-off was used. Ultrasonic coupling gel was
liberally applied to the stand-off and clipped area of skin.
All examinations were videotaped for subsequent examina-
tion.?
A variety of scanning locations and directions were
evaluated in all dogs, including transverse and longitudinal
orientation. Each scan position was evaluated for consis-
tency and repeatability of image formation. A scan position
was considered useful when anatomical structures could be
readily identified with minimal artifactural disruption in all
dogs. Recognition of structures considered important for the
clinical diagnosis of common laryngeal diseases also influ-
enced the choice of scan position.
Accurate identification of anatomic structures was en-
sured by repeating the ultrasound examination on three
Greyhound cadavers. Under ultrasound guidance, 3.5-in
spinal needles were directed into structures whose anatomi-
cal identity was uncertain. Careful dissection of the pharynx
and larynx was then performed until the tip of each spinal
needle was located. This location was correlated with the
position detected during the scan.
Laryngeal movements were accentuated in all dogs by
exercising them for periods of up to 15 minutes. Scans were
repeated in the panting animal, with specific attention paid
to detecting abduction and adduction of the vocal cords.
To measure movement of the vocal cords objectively,
pulsed-wave Doppler recordings were made in all living
subjects. Using a sample volume of 1.0 mm, the gate was
placed along the medial edge of the vocal cord in the rested
animal. Doppler recordings were obtained over a period of
four respiratory cycles in all dogs. The dog was then exer-
cised for a minimum period of 10 minutes, until it was
panting during the course of the ultrasound examination.
Pulsed-wave Doppler recordings were obtained as described
above.
Results
Consistent ultrasonographic images of pharyngeal and la-
ryngeal structures were obtained in all dogs in this study. No
animal required sedation for the examination. Aside from
the absence of respiratory movements, no differences were
observed between ultrasound images obtained from the ca-
daver and the living dog.
Transverse scans provided the most consistent and inter-
*Apogee 800, ATL UK Ltd. Letchworth.
tSony SVO-9500MDP S-VHS video recorder.
567
pretable images of the pharynx and larynx. More impor-
tantly, transverse scans revealed the symmetric anatomy of
larynx. Longitudinal scans were not found to provide im-
ages of similar quality. Transverse scans were performed at
two locations. In the first, the probe and stand-off were
placed on the midline immediately cranial to the basihyoid
bone. The probe was initially directed cranially and was
then rotated slowly through a 20 to 30" arc during the scan.
The probe was then moved caudally to the second probe
position directly on the cricothyroid ligament. As in the first
position, the probe was initially directed in a cranial direc-
tion before being slowly rotated through a gentle arc; en-
suring that the probe remained centered on the midline
throughout the entire scan (Fig. 1).
At the cranial extent of the first transverse scan position,
the caudal region of the tongue was recognized as a hypo-
echoic, slightly ovoid structure. Its dorsal circumference
was outlined by a hyperechoic signal. The paired, hyper-
echoic geniohyoideus muscles were visible ventral to the
tongue, splitting into two distinct bellies at their insertion on
the basihyoid bone. Moving further caudally to the pharynx,
the cranial aspect of the epiglottis became visible as a dif-
fuse, hyperechoic structure (Fig. 2). Its margin was indis-
tinct because of the presence of surrounding air in the oro-
pharynx. This region of the scanned area was associated
with a variety of artifactual and noninterpretable images,
because of the presence of air within the oropharynx. How-
ever, if the animal was made to swallow while the probe
was held steady, the craniocaudal movements of the epi-
glottis were visible. At the more caudal extent of the scan,
the profile of the epiglottis became more distinct, with a
curved base and hyperechoic centre (Fig. 3). With continued
caudal rotation of the probe, only the base of the epiglottis
FIG. 1. Saggital cadaver preparation to illustrate recommended probe
positions for ultrasonography of the pharynx and larynx. This also illus-
trates the position of the vocal cords and the need for precise orientation of
the ultrasound probe to minimize acoustical artifacts.
Modified from Boyd JS. Color Atlas of Clinical Anatomy of the Dog and
Cat. St. Louis: Mosby-Wolfe, 1991, with permission.
568 BRAYET AL 1998

A margin. In all dogs, intraluminal air prevented visualization

of the dorsal aspect of the larynx. At the caudal extent of the
scan, the cricoid cartilage appeared as a bean-shaped hypo-
echoic structure, continuous with the trachea. The presence
of air again prohibited visualization of the dorsal circum-
ference of the cricoid cartilage.
In the resting animal, there was little detectable change in
the position of the vocal cords during breathing. In the
panting animal, however, slight adduction and abduction of
the vocal cords was visible with inspiration and expiration,
respectively. This respiratory movement was evident by
variation in the size of the central hypoechoic signal when
the probe was held steady. This movement was coordinated
with inspiration and expiration by the animal.
Pulsed-wave Doppler tracings could be obtained from the
medial edge of each vocal cord only. Aside from an increase
in respiratory rate, the tracings were similar in both the
resting and exercised animal and were obtainable during the
B inspiratory phase only. The resultant recording suggested a
low-frequency vibration, with a velocity of less than 0.1 m/s
(Fig. 6).

FIG.2. Transverse scan (A) and rendition (B) of the pharynx with the
probe positioned in just cranial to the basihyoid bone. Structures are in-
distinct because of air, but the epiglottis can be seen, particularly if the
animal swallows. Immediately ventral to the larynx, the hypoechoic my-
lohyoid muscle is visible as it inserts on the basihyoid bone (marked *).

was visible as a hyperechoic line. The cranial margin of the

thyroid cartilage was also seen immediately ventral to the
epiglottis (Fig. 4).
The probe was then moved to the second transverse PO- B
sition on the cricothyroid ligament. Accurate positioning of
the probe in the second transverse scan position was ensured
by visualizing the inverted V-shaped, hyperechoic structure
determined to be the ventral aspect of the thyroid cartilage
(Fig. 5). The extrinsic muscles that lie ventral to the larynx
were visible as paired, symmetrical hypoechoic shadows
covering the ventrolateral aspect of the thyroid cartilage.
With the probe initially directed cranially, the base of the
epiglottis and tip of the thyroid cartilage were visualized as
before (Fig. 4). With slow caudal rotation of the probe,
maintaining_precise
. orientation to the midline, the vocal
cords became visible as paired, hypoechoic triangular struc-
FIG.3. A more distinctive profile of the epiglottic cartilage [scan (A),
tures between the V-shaped thyroid The rendition (B)] is visible at the more caudal extent of the first scanning
margin of each vocal cord was outlined by a hypoechoic position. The actual margin of the epiglottis is outlined in A to aid clarity.
VOL. 39, No. 6 569

A diagnostic image being obtained at any one time, necessi-

tating considerable patience by the operator. Despite this, all
structures described in this paper were observed in each
dog, and, with progressive familiarization with the tech-
nique, diagnostic images were obtained quickly and consis-
tently.
Previous reports on ultrasonography of the canine neck
have excluded specific mention of the regional airway struc-
t u r e ~ . ' ~ 'The
~ ' high acoustic impedance mismatch of a soft
tissue and gas interface was generally considered to prohibit
image formation of air-filled structures. In this study, diag-
nostic images of laryngeal movement required precise ori-
entation of the scanning plane directly along the vocal
cords. Incorrect orientation resulted in a high level of arti-
factual and acoustic shadowing caused by the presence of
air within the lumen. A diagnostic image that permits evalu-
ation of laryngeal movement will be obtained only if the
sound wave from the ultrasound probe passes directly along
the,length of the vocal cord. Misdirection of the probe by
more than a few degrees cranially or caudally exposes more
air within the laryngeal lumen and increases the incidence
of acoustic shadowing,
Transverse orientation of the scans were considered to
provide the most useful structural information about the

FIG.4. Moving the ultrasound probe to the second scanning position, the
cranial extent of the larynx is identified by two hyperechoic bands-the
thyroid cartilage ventrally (open arrows) and the base of the epiglottis
dorsally (closed arrows) [scan (A), rendition (B)].

Discussion
The results of this preliminary study indicate that ultra-
sonography is a noninvasive and easily reproducible means
of evaluating the structure and dynamic function of the ca-
nine pharynx and larynx. A variety of breeds and ages of
dog were examined successfully. This is contrary to reports
of laryngeal ultrasonography in the human, where exami-
nation is limited to the pediatric patient, because calcifica-
tion of the laryngeal cartilages in the adult precludes image 6
formation. Although calcification of canine laryngeal carti-
lage has been reported,16 it was not determined whether any
of the animals used in this study had laryngeal calcification.
It is likely that the ability to ultrasound the larynx of adult
animals successfully in this study reflects the generally
smaller size of the canine larynx, as compared to the human.
All patients in this study tolerated the procedure well, and
none required sedation. However, production of a diagnos-
tic image required precise probe positioning on the crico-
thyroid ligament, an area sensitive to even light pressure. FIG.5. Slow, caudal rotation of the probe in the transverse plane will
provide identification of the vocal cords [scan (A), rendition (B)]. Slight
Some dogs quickly lost patience with the study, and their -
adduction and ahduction of thc rncdinl c d p x of thc voa;rl aor& oun bc
frequent head movements resulted in only brief periods of a detected during inspiration and expiration in the panting animal.
570
FIG.6. Pulsed-wave Doppler recordings from the medial edge of the vocal cords provide a trace during inspiration only. In all dogs, this was recorded
with a velocity of less than 0.1 m/s both at rest and exercise.
pharynx and larynx. The natural symmetry pertaining to
structures in this region was clearly identified in the result-
ant scans. This was considered advantageous for diagnosis
of diseases that may disrupt this symmetry (e.g., laryngeal
paralysis, laryngeal neoplasia). Although longitudinal scans
were assessed in all patients, the resultant images were more
varied in their interpretation and seemed to yield little ad-
ditional information. However, the evaluation of other scan
positions for laryngeal ultrasound is continuing.
In the resting animal, laryngeal movements were mini-
mal, but these were accentuated when the animal was
breathing heavily. This finding is similar to reports of la-
ryngeal ultrasound examination in the human. Human sub-
jects can be asked to increase the depth of their respiration
during the course of the ultrasound investigation. Deep in-
spiration resulted in readily identifiable adduction of the
vocal cord.'"'4 In this study, the animal was made to pant
heavily by exercising. Adduction and abduction of the vo-
calk muscle and arytenoid cartilages was visible, accentu-
ated by changes in the acoustic shadow in the rima glottidis.
Pulsed-wave Doppler is commonly used for cardiovascu-
lar investigation to assess speed and quality of flow through
the heart chambers and blood vessels. The change in fre-
quency of a sound wave reflected from a moving object can
be compared with the original frequency to determine the
velocity of the object and whether the movement is toward
or away from the probe. In this study, pulsed-wave Doppler
was investigated to determine whether vibration of laryn-
geal structures during respiration could be measured.
One characteristic clinical feature of laryngeal disease is
BRAYET AL I998
development of a stridor or stertorous noise during inspira-
tion and/or expiration, a product of air turbulence and tissue
vibration. The current investigators were, therefore, curious
to discover whether pulsed-wave Doppler could be used to
identify evidence of movement within the normal larynx.
This study has shown that pulsed-wave Doppler recordings
can be obtained only from the very medial edge of the
vocalis muscle. The spectral display records a range of fre-
quencies with movement oscillating equally toward and
away from the transducer at a low rate of 0.1 d s . Move-
ment was recorded during inspiration only. This measure-
ment may, therefore, reflect muscular contraction and vi-
bration of the vocal cords.
The ability to visualize and measure movement of laryn-
geal structures with ultrasound has important significance in
the diagnosis of several laryngeal diseases currently recog-
nized in the dog, including laryngeal paralysis and laryngeal
collapse. Diagnosis of these conditions currently relies upon
visual assessment of laryngeal movement in the lightly
anesthetized animal. '-338210 However, it is well recognized
that anesthesia will suppress muscular activity of the larynx.
Careful assessment of any laryngeal movements that occur
as the animal regains consciousness is necessary for a reli-
able diagnosis to be made.3 Furthermore, recovery from
anesthesia may prove complicated in some animals with
severe laryngeal disease, and placement of a temporary tra-
cheostomy may be necessary until consciousness, and a
normal respiratory pattern, is regained. The use of laryngeal
ultrasound in the human permits visualization of abnormal
movement of the vocal cords for diagnosis of bilateral and
VOL. 39, No. 6
unilateral laryngeal paralysis,13215
and the authors speculate
that similar observations are possible in the dog. The ability
to perform this investigation in the conscious animal has
obvious implications. Clinical studies are currently under-
way to investigate the value of ultrasound in the diagnosis
of laryngeal disease in the dog.
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