Surgery of the upper airways in

horses

Prof. Gábor Bodó, DSc, Dipl. ECVS

2021
 U
I. Nasal opening and passage P
P
E
II. Sinuses
R

III. Guttural pouch A

I
R
IV. Pharynx
W
A
V. Larynx Y

2
 Disorders of the Nasal Passages

Trauma

• Nasogastric Tube (NGT)

- 5-10 min. bleeding
- Use the ventral nasal passage!

• (blunt) Trauma
→ Impression Fracture
→ Foreign body
3
 Disorders of the Nasal Passages
Progressive Ethmoidal Haematoma (PEH)

• Etiology Unknown

→Submucosa-Bleeding: Ethmoid
Turbinate Region
• Circumscribed, Expansive,
Red-Brown Mass

• Can Invade into the Sinuses

4
It Showed up Yesterday….

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 Disorders of the Nasal Passages
Progressive Ethmoidal Haematoma
normal PEH
Diagnosis:
• Endoscopy, (Biopsy)
• X-ray / CT/ MRI
Diff. Diagn (DD):
• Neoplasia
• Mycosis/ Ulcerative Rhinitis
• Foreign Body, Sinus Cysts,..

6
 Disorders of the Nasal Passages
Progressive Ethmoidal Haematoma
Treatment:
• Transendoscopic
– Formalin-Injektion / Laser
– Management lifetime

• Sinusotomy- Approach
→ Surgical Exstirpation
→ Laser / Cryotherapy
→ Blood Loss!
Often Recurrent (40%+)

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PProgressive Ethmoid Hematoma

8
Injecting formalin into the tumor
 G
u
Guttural pouch tympany tt
Guttural pouch empyem u
r
Guttural popuch mycosis:
a
• Occlusion with balloon catheter (ACI, l
ACE, APM) p
• Coil embolisation o
u
Temporohyoid osteoarthropathy
c
h9
 E
T

I R H

S: stylohyoid bone; E: External carotid artery; M:maxillary artery; T: tensor

veli palatini muscle; E, cartilaginous portion of eustachian tube; I: internal
carotid artery with hypoglossal and glossopharyngeal nerves lateral to it; R:
ventral straight muscles (M.rectus capitis); H, median septum.
10
 GP neuroanatomy

Auer&Stick: Equine Surgery – 4th Ed.

Roof lat. compartment: CN VII (facial n.), CN V/mandiblular branch, CN VIII (vestibulocochlear n.)
Floor med. compartment: cran. Laryngeal n. + pharyngeal branch of CN X (vagus).
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 GP Tympany

• Predisposing factors:
– Arab, Paint horse
– filly > colt
– unilat > bilat

• Age: few days-> few months – > yearling age

• Cause
– Plica salpingopharyngea one way valve
– No anatomical disorder 12
 GP Tympany

• Clinical signs:
– Not painful, air-pillow palp.
– Unilat looks like it is bilat!!

• Diagnosis
– Based on clinical signs
– Endoscopy: pharynx often collaps dorsally
– You can achieve decompression during endoscopy
– Röntgen
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 GP Tympany

• Treatment:
– Foley catheter for 2-3 weeks
– Transendoscopic laser surgery
• Septum fenestration
• Mucus membr. Fold removal from the
med. plica salpingopharyngea

Pictures: G. Bodo 14
GPM bleeding – second time

15
 Guttural pouch – clinical
examination
Visual examination:
• Bloody-braunish nasal discharge,
• Excessive nasal bleeding
Palpation

Radiological examination:
– Mycotic plugs

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 Guttural pouch mycosis
Cause: Aspergillus spp.
Symptoms:
• Bloody-braunish nasal discharge,
• Excessive nasal bleeding, more liters!!
• Second, third attemt -> bleeds to death
Treatment:
• Depends on location of mycotic attack
• Arterial occlusion:
– coil embolisation
– Balloon catheter occlusion

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A: proc. corniculatus – arythenoid cartilage
B: dorsal pharyngeal wall
C: blood coagulate in the entrance of the left guttural pouch
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20
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23
Ballon catheters inserted into 3 arteries

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25
Functional disorders: P
• Dorsal displacement of the soft
palate (DDSP) h
• Pharyngeal collapse
• Head and neck position
a
r
• Developmental abnormalities:
– Palatoschisis
y
– Choana atresia n
• Masses and scars in the pharynx
x
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 „Function“
• obligate nasal breather
• Differences in Pressure
rest→exercise
– Excessive differences
• Air volume
• Intraluminal pressure

Rest: 75 l/min
Max. exercise: 1500 l/min

Exspiration Inspiration 27
 Functional disorders: pharynx
• Most of them are dynamic
• 30% have multiple disorders
• DDSP
• soft palate instability
• pharyngeal collapse (rostral, lateral or dorsal pharnygeal wall)

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What is your diagnosis?

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Paryngeal Lymphoid Dorsal Displacement of
Hyperplasia (PLH) the Soft Palate (DDSP)

30
 Ultrasound!

Os basohyoideum in transversal plane

Depth is significant in DDSP

Auer: Equine Surg. 4th Ed.
31
DDSP

Incidence: 10-20% in 1-2-year old racehorses

Etiopathogenesis:
– Inappropriate intrinsic muscular contraction of SP
– less dorsal position of the larnyx and basohyoid bone
– Tongue position?
– Flaccid epiglottis (rather a result not the cause of ddsp
Clinical signs:
– Exercise intolerance during intense exercise
– Vibrating noise during exhalation
– Open-mouth breathing („”choking down” – trainer)
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DDSP- Treatment
Conservative at the beginning:
• Treating inflammation if present
– Dexametazone iv.
– throat spray (DMSO, nitrofurazone, dexa. Glicerin)
• Tongue-tie, „Cornell collar“
• Training for one year at young racehorses
– Figure 8 noseband → keep mouth closed

60-80 % success rate

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 iDDSP (i=intermittent)
→ „Pharyngeal muscle Weakness“:
– 6-8 months regular exercise

→Surgical Treatment:
– laryngeal tie-forward
– Myectomy (M. sternothyreodieus)
– Staphylectomy ??
– Scarring of the soft palate with laser
– Epiglottis augmentation ???
=>Combinations
Prognosis: 50 - 60 %“
80% following tie-forward? 34
 Tie-forward

Rossignol (2012 Vet Surg)

Auer:Equine Surgery 4th Ed. 35
preop postop
36
 Pharyngeal Collapse

• rostral pharyngeal collapse =>DDSP (?)

→ noise during exspiration
mild dorsal pharyngeal collapse

• dorsal/lateral nasopharyngeal collapse

→ noise during inspiration

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 Complications

• Dysphagia (→ Aspiration pneumonia)

• Disturbances in wound healing (Serom,…)
• Development of other (dynamic) disorders:
→ iDDSP→Staphylectomy→pDDSP
→ iDDSP→tie forward→vocal cord collapse (VCC)

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 Congenital Defects
Choana Atresia ethmoid recess

• Seldom malformation
• persistent buccopharyngeal
membran
• unilateral → can be James et al, JAVMA 06

asymptomatic at rest →
1-2-y -> surg. intervention
• bilateral → Tracheotomy →
Laser-resection, „stenting“

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 Palatoschisis
• seldom, congenital disorder
– Soft palate and/or hard palate
• Must be recognised in the
newborn foal (umbilicus/abdominal
wall,soft palate, ribs etc.)

• Milk is coming back through

the nose, cough,…

Kép: C.Koch Dipl. ACVS

40
 Palatoschisis
• Euthanasia or Palato-plastica?
Kép: C.Koch Dipl. ACVS

→ Aspiration pneumonia?

With minimal tissue loss: 50% chance

If hard palate is involved: prognosis is bad
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Palatoschisis with hard palate
ivolvment
Do not try!

Kép: C.Koch Dipl. ACVS

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Kép: Bodó G

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 Pharyngeal cysts Kép: Bodó G

• Where?
– Subepiglottial
– In pharyngeal wall
– In soft palate

• Removal:
– Surgical excision
– Laser

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Dynamic disorders larynx:
• Rercurrent laryngeal Hemiplegia (RLH)
•
•
Axial deviation of the aryepiglottic fold
Proc. corniculatus apex collapsus
L
• Intermittent epiglottis entrapment A
• Epiglottis retroversion
R
Permanent disorders Y
•
•
Epiglottis Entrapment
Arytenoid chondritis
N
• Subepiglottial cyst X
• 4 BAD
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46
Anatomy

(gégefedő)

47
Anatomy

EQUAD

48
Anatomy

49
Anatomy
Anatómia

50
Anatomy

51
Anatomy

52
Anatomy

53
Anatomy
Kannaporc
Gyűrűporc

Pajzsporc

54
Anatomy

55
Anatomy

56
Anatomy

57
Anatomy
natómia

58
Anatomy

59
 Anatomy

N. Laryngeus cran int. N. Laryngeus cran ext.

N. laryngeus recurrens

Budras: Anatomy of the horse 5th Ed.

60
 1. Epiglottis apex
5 8 2. Epiglottis
4 7
3. Plica aryepiglottica
9 4. Kannaporc
3 5. Palatopharyngeal arch
12
2 13 10 6. Pajzsporc
1
11 7. M. arytenoideus transv.
6
8. M. CAD
9. Gyűrűporc
14 Extensor of the vocal cord 10. első trachea gyűrű
11. M. cricothyroideus
12. Foramen N. LC szamara
13. Pajzsporc-nyelvcsonti ízület
6 9 14. Pajzsporc prom. ventr. része
3 5 7 10
8
4
1 2
4 8
5
7

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Innervation of Intrinsic Pharyngeal
Muscles
• Abductor • Adductor
– M. CAD - NLR – M. A. transv. - NLR
– M. CT – NLC ext. branch – CAL - NLR
– M. TA - NLR

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Head and neck position

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Hemiplegia laryngis

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 Terminology

• Recurrent Laryngeal Neuropathy – RLN

• Idiopathic Laryngeal Hemiplegia -ILH

• „Hörgősség”
• Roarer (English), Kehlkopfpfeiffer (German),
• Cornard (French), Corneggio (Italian)

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 Pathogenesis- Hemiplegia laryngis (RLN)
• Idiopatic
• Progressive degeneration of dist. fibres
of NLR sin. (axonopathy)

• Genetic predisposition
• Large horse breeds
• At younger age
– From a few months up to 10 years

NLRS. prox. NLRS. dist

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 N. Laryngeus recurrens

Turns back around the aorta arch (just on the left side)
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68
 Other causes (≈ 6%)
• Stangles
• Guttural pouch mycosis
• Perivascular inj, Periphlebitis
• Operations (crib biter OP)
• Intoxications, (Led, organophsph.)
• Tumors (neck, thorax)
• CNS (EMND)

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 Clinical signs

• Noise at Inspiration during excercise

• Poor performance

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Increased inspiratory noise

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 Definition: paresis-paralysis of RLN, leading to
m. athrophy, vocal cord collapse and
arythenoid cartilage collapse during inspiration

72
 Diagnosis

• Palpation (CAD-atrophy)
• US of the larynx
• Endoscopy at rest
– Abduction following swallowing/closure of the nares
– slap test (contralat. Adductio – Cervicolaryngeal Reflex)
• Dynamic Endoscopy (DRE or treadmill)
• Noise (voiceprint, spectrogram)
• Spirometry
• Lobelin-stimulation
73
Palpation

74
 Ultrasound

8,5 MHz micro-convex probe

TC
TC
CAL CAL

AC AC
Auer: Eq. Surg. 4th Ed.

Sound larynx RLN

75
…what do we have to see?

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RLN Grades at Rest 1.

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RLN Grades at Rest 2.

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 DRE /Treadmill

Nyugalomban Grade „4” Terhelés alatt „C”

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Barakzai and Dixon EVJ 2011

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„”weak correlation between resting and
dynamic endoscopy!!”
• Parente et al. 1995,
• Perente et al. 2002,
• Lane et al. 2006,
• Barakzai and Dixon 2011

DRE kontra treadmill endoscopy

• „more natural” circumstances
• Rider and trainer freundly
• (disadvantage: racing speed is more difficult to force?)
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Dynamic Respiratory Scope
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Dynamic Respiratory Endoscopy
Dr. Fritz Instruments DRE 83
 Hemiplegia laryngis - Treatment

• Laryngoplasty (LP) + Ventricul(ocord)ectomy(V, VC)

• Arytenoidectomy ( if LP unsuccessfull)

• Future: Pacemaker?

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Sir Frederick Hobday
1870-1939

Plósz Béla Professzor

1863-1945

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 Laryngoplasty
First described: Marks et al. in 1970

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Ventriculectomy

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Fotó: Bodó G

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Fotó: G. Bodó

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Fotó: G. Bodó

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 Cordectomy / Ventriculocordectomy with
Laser
„If only the noise but no poor performance”:
• bilat Ventriculocordectomy with 3-4 weeks
interface
• Standing, transendoscopic approach
– Nd:YAG or Diode Laser
immediate postop One day postop 6 months postop

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 Transendoscopic
Laser Surgery

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Laser ventriculocordectomy 1.

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Laser ventriculocordectomy 2.

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Laryngeal pace-maker: the future?
(Prof. N. Ducharm - Cornell)

Ducharm et al EVJ 2010

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 Postoperative Rehabilitation

• 4 weeks walk on hand

• 2 weeks light excercise
• Build up training
• 6-8. weeks: controll examination
– Endoscopic examination

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 Complications
• Laryngospasmus
• Ödem, Serom (7 – 30%)
• Wound infection (0,5 – 6%)
• Cough (43%, after 6 M.: 14%)
• Repeated LP (10% weak; 7% too tight)
• LP not holding (2-20%)
• Dysphagia (< 1%)

97
 Vanperformance
Poor legjobb műtéti megoldás?
following LP / + V
or VC
E.Davidson … E. Parente: Vet.Surg.2010

CAUSES:
• Arythenoid cartilage collapse (failed tie-back)
• Right sided vocal cord collapse
• Axial deviation of the right aryepiglottic fold

98
Axial deviation of the
Aryepiglottic Fold

99
Occurance

• Just dynamic disorder

• Oft bilateral, if not, than right sided
• Race horses, (event horses)

100
 Treatment

• Transendoscopic Laser excision

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???

102
 Clinical signs
• Poor performance
• Worse with time
• More frequent in older horses Auer: Equ.Surg.4thEd
• Often chronic
• Don’t mix it up with RLN!!
• Acute:
– perichondrial ödem
– fever, lethargic, leucocytosis
• Ulceration
• Kissing lesion
103
 Treatment

• Acute:
– AB, NSAIDs, „throat spray”
– Tracheotomy – in emergency

• Chronic:
– Partial arytenoidectomy

104
Epiglottic entrapment

105
 Occurance, Clinical Sings

• Persistant (97%), seldom dynamic

• Thickened (97%)
• Ulcerated (45%)
•31-36% together with epiglottic hypoplasia

106
 Clinical Signs

• Primarly inspiratory noise

• Poor performance in race horses

• Can be just an endoscopic finding

• Coughing after drinking water

• Nasal discharge

107
 Treatment Diode Laser
F. Rossignol
ECVS 2012

Auer: Equine Surgery 4th Ed

Curved Bistoury

Nasopharyngeal forceps

108
Subepiglottic Cyst

109
 Occurance, Clinical Signs

• Young race horses

• Foals (congenital form?)

• Cough
• Noise during inspiration (asphyxia)
• Dysphagia, aspiration pneumonia

110
 Soft palate cyst
Diagnosis
• Endoscopy
• Lat-lat X-rays
• Palpation though the mouth(small hand☺)
epiglottis

Treatment
• Minifötotom” oral extraciton
• Laryngotomy
– submucosal excision
• 4% intrathecal formalin-injeciton
• Laser
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Fotó: G. Bodó

112
4 BAD

OK
left

DEFECT
right

4th Branchial Arch Defect (4BAD)

113
What’s your diagnosis?

114
What’s your diagnosis?

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The same case after 6 months

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 Take home message
1. Resting endoscopy is not always relevant to diagnose
the cause of respiratory noise.

2. Upper airway surgery need exact anatomical knowledge

and huge experience
3. Most frequent disorders are: RLN and DDSP

4. Right sided laryngeal paralysis? - 4 BAD!

5. DDSP: noise during expiration

6. Cysts, entrapement: nice scar (laser)

– little tissue loss is advantageous 117
Thank you for your attention!

NPZ Bern

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