In his last article , surgery expert Aidan McAlinden explained the indications for surgery in dogs with ‘Brachycephalic Upper Airway Obstructive Syndrome’ . In this article he describes the surgical procedures used to correct the defects and what happens after surgery. What does the surgery involve?
A patient with Brachycephalic Upper Airway Obstructive Syndrome positioned for the surgical procedure. The mouth is held open with the use of tape and the tongue is retracted to provide access to the soft palate. The endotracheal tube (arrow) can be seen entering the airway for the delivery of anaesthetic gases and oxygen.
1. Surgical resection of the elongated soft palate This is the first stage of most operations. The excess length of the soft palate impinging upon the opening of the larynx is removed. This can be performed in several ways such as; standard surgical excision with scissors, using a surgical cautery unit or using a surgical laser depending on individual surgeon preference.
The beginning of the soft palate resection. Sutures are placed into the palate and used to retract the edge toward the surgeon and stabilise it during resection
There is an additional technique first described approximately five years ago that your veterinary surgeon may offer, called a folding flap palatoplasty (FFP). It differs slightly in that it addresses the excessive thickness of the palate in addition to the excessive length if this is deemed necessary. It is more technically challenging but the results so far are promising. This is my procedure of choice if the palate also thick – a common finding in Bulldogs.
2. Resection of the laryngeal saccules This is the second stage in most operations. There are two small pouches located just inside the larynx (voicebox) in front of the vocal cords. These can be sucked inside the larynx by the negative pressure created during laboured breathing. Once turned inside out, these saccules cause a physical obstruction to airflow through the larynx. Most surgeons refer to this as ‘grade I’ laryngeal collapse and will remove the saccules.
A completed rhinoplasty / naroplasty on this Pug’s right nostril (arrow). Notice the difference in the size of the nostril opening.
3. Rhinoplasty / Naroplasty This is the third and final stage for most patients. A small wedge of the tissue on the outside of the nostril is removed and stitches are placed into the wound so that the nostril opening is widened. These sutures are absorbable and usually cut quite short to limit irritation.
Recovery The patient is transferred to a recovery area and very closely monitored as they come around from their anaesthetic. Particular care is paid to their ability to breathe as any swelling in the larynx or throat could lead to obstruction, although this is uncommon. However if this complication develops, the anaesthetic tube may need to be replaced and anti-inflammatory medication administered before another attempt at a very gradual and slow recovery. Failing this, a small tube may need to be placed directly into the windpipe (called a tracheostomy) to allow air to bypass the obstruction. The patient would then breathe through this tube until the swelling settles and then can breathe normally again. This could be in the order of 24-48 hours and they would need to be hospitalised and continually monitored. It is important to say that this is a rare situation after this surgery.
What is the prognosis? The vast majority of patients with Brachycephalic Upper Airway Obstructive Syndrome experience a significant improvement after their surgery. However it is important to note that this surgery does NOT make them breathe in a completely normal fashion. About three quarters of all dogs will still make snoring sounds when sleeping and half may still have noisy breathing.
Therefore the main aims of this surgery are two fold;
To reduce the severity of respiratory symptoms
To prevent or slow the progression of secondary laryngeal collapse
Most owners rate their dog’s outcome as good in the long-term.
What does it mean if my dog has laryngeal collapse diagnosed at the time of surgery? It was generally accepted that only grade I laryngeal collapse can be managed surgically. There were no options for more serious grade II and III laryngeal collapse apart from a permanent tracheostomy (creation of a permanent opening into the windpipe to breathe through) if the patient did not improve sufficiently following the surgery described above.
Recent evidence suggests that a procedure commonly referred to as a ‘tie-back’ may be employed as a salvage procedure to avoid a tracheostomy in these cases. This surgery involves placement of sutures into the cartilage of the larynx to hold it ‘open’ on one side. You could consider the analogy of how a tie-back holds a curtain open over a window!
However as mentioned above, most dogs benefit from the standard surgery even if they have secondary laryngeal collapse, and tie-back surgery is only considered in the minority of cases that do not improve or in those that deteriorate after a period of remission. Referral to a specialist veterinary surgeon experienced in the management of this condition would generally be recommended.
What aftercare is involved? In most instances these patients stay in the hospital for 24-48 hours after surgery. This is to allow their breathing to be monitored and the provision of pain relief as required (although they are usually relatively comfortable over the post-operative period).
Upon returning home, it is important that they are encouraged to rest and avoid vigorous activity, stress or exposure to excessive heat for approximately two weeks. Soft food is normally offered over this time period until the palate wound has healed. Normally the sutures dissolve over time but a check-up would normally be performed two to three weeks after surgery with further rechecks only arranged if necessary.
It is important that these patients are kept lean and not allowed to gain excessive weight. The brachycephalic breeds have a tendency to accumulate body fat around their neck and this can contribute to the progression of laryngeal collapse.
About Aidan McAlinden
Aidan is a Diplomate of the European College of Veterinary Surgery. He recently worked as a surgeon at Davies Veterinary Specialists, one of the largest multi-disciplinary referral centres in Europe. He is currently Lecturer in Veterinary Surgery at University College Dublin where his busy case load comprises cats and dogs requiring ENT, cardiothoracic, abdominal or cancer surgery.
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