GDV

GDV

Ava

Gastric Dilatation and Volvulus (GDV)

Gastric dilatation and volvulus is commonly called GDV and even more commonly referred to as bloat. The term bloat is somewhat of a misnomer because that really only describes half of the issue. This condition occurs when the stomach both dilates (fills with gas and/or fluid) and rotates on its axis. Unfortunately, we never know which happens first the rotation or the dilation. Regardless, surgery is necessary in order to correct the issue and prevent recurrence, we will describe the procedure below.

This condition most commonly occurs in the large/giant breed dogs and deep chested breeds. It is rarely seen in small and medium size breed dogs. The most common breeds are the Great Dane, Mastiff, etc – you get the picture. Surprisingly, in addition to the larger breed dogs, we also see it in Standard Poodles more frequently. There are a lot of theories out there as to why this may occurs. Some common thoughts range from frequency and size of meals, exercising after meals, elevation and height of bowls, etc. We also see an increase in GDV incidence in dogs that have other types of gastrointestinal disease, such as inflammatory bowel disease.  Stressful environments such as pets being hospitalized, boarding, storms, etc. can increase the risk of this issue too. As a practicing surgeon, I can’t tell you how many times, dogs that present with a GDV are coming from a referring veterinary hospital, boarding facility, the pet-sitter, etc; so it is a real problem. A lot is done to avoid some of these situations to try to prevent this from occurring, the most definitive way to avoid this is to have a prophylactic gastropexy performed either by your veterinary or veterinary surgeon. I will address these techniques later on in the series, and we will spend some time on it, because this can be performed very easily by minimally invasive techniques.

Clinical Signs

Some of the most common signs an owner will see include the attempt to vomit, which is termed non-productive retching. This occurs due to the junction of the lower esophagus and stomach being rotated >180 degrees in effect kinking this area. Other signs are signs of discomfort such as listlessness and the inability to get comfortable. Also, many times you will notice enlargement of the abdomen. In cases that have been going on for some time (even a few hours) you can see dogs that are unable to get up and/or not responsive to stimuli.

As described above, this condition can progress rapidly and be fatal, so immediate veterinary care is a must. This condition not only directly affects the stomach and gastrointestinal system, but also affects the cardiovascular system (compression of the vena cava and return flow to the heart) which places these patients in shock and can propagate various inflammation and coagulation cascades that can also cause death. The spleen can also become affected due to its close proximity ad shared blood supply from the stomach. As the stomach rotates these splenic vessels can become torn.

Diagnosis

An experienced veterinarian will be able to quickly diagnose this condition, based on signalment (breed), clinical signs, and physical examination. Radiographs (X-rays) generally leave little doubt, as there are “tell-tale” signs seen on x-rays. Blood work will also be performed to assess values such as red blood cell concentration, electrolyte abnormalities, lactate, etc all factors that will be used to guide initial stabilization and treatment prior to surgery. Once diagnosed, surgery is required. If surgery is not feasible (patient is not able to be stabilized, owner unable to move forward with surgery, etc), humane euthanasia will be likely recommended.

This is a right lateral abdominal x-ray. Note the large, dilated stomach and evidence of the duodenum (intestine) just above the stomach and below the spinal column.

This is a right lateral abdominal x-ray. Note the large, dilated stomach and evidence of the duodenum (intestine) just above the stomach and below the spinal column.

Treatment

As one may assume anesthesia is more risky in a sick animal, but is needed for this problem. Unfortunately, there is no conservative/ non-surgical approach that has been shown to work. After immediate stabilization of the patient, surgery is indicated.

The surgical goals are to decompress the stomach, place the stomach in the correct position, and attach the stomach to the body wall – to drastically decrease the chance of this happening again. The last part of the procedure is called a gastropexy, dogs that do not have this performed, are at high risk for this to happen in the future.

Other things that need to be evaluated while in the abdomen are the stomach – there are times where necrotic (dying) segments of the stomach must be removed. Unfortunately, there are times where gastric (stomach) necrosis is so profound or is affecting a non-resectable location of the stomach when humane euthanasia may be recommended. Thorough evaluation of the spleen is necessary and a splenectomy may need to be performed. After these organs are evaluated, the rest of the abdomen is evaluated.

Post-operative care is also very important, since many cases are not completely straight forward. Close monitoring, aggressive fluid therapy and appropriate management is necessary for a successful outcome. More recent reports show an 80-85% survival rate (with straight forward cases), which is much higher than previously thought. The more damage done (gastric death, spleen involvement, etc), the worse the outlook. Again, a quick response and aggressive management is what is needed.

Prevention

While there are many different views about how to decrease the chance of a GDV occurring, the most successful way is to have a prophylactic gastropexy performed. A gastropexy is a procedure that attaches the pyloric antrum segment of the stomach to the body wall. While this does not prevent dilation of the stomach, it does prevent the deadly rotation of the stomach.

When is the best time to have this performed? I recommend this procedure be performed at 6 months or older. This timing of the procedure coincides with spaying and neutering of your pet, both procedures can be performed at the same sitting. This procedure is especially easy in female dogs that are being spayed, since the abdomen is already open.

Recently, we have the advantage of doing this procedure and the spay procedure via laparoscopy. Laparoscopy is a minimally invasive procedure in which small incisions (0.5-1.0 cm) are made in the abdomen and the organs are visualized on a screen with cameras and surgery is done with small instruments through these incisions. The laparoscopic gastropexy is typically a very fast and effective procedure and is commonly combined with a laparoscopic ovariohysterectomy (spay). Contact your veterinarian for details about this procedure or a referral to a veterinary surgeon who can perform this procedure.

New Total Hip Replacement Video

New Total Hip Replacement Video

Take a look at our new Total Hip Replacement (THR) video. This happy dog is a recent (last fall) recipient of a total hip replacement at AVS Orange Park. As you can see, he is a very happy boy and much happier now that he is feeling better!! Please contact us with questions or if you feel that your dog may benefit from a THR.

Total Hip Replacement video

February 2016 – Case of the Month.

February 2016 – Case of the Month.

I am getting this in by the “skin of my teeth” before February ends, no pun intended since it is Pet Dental Health Month! In the spirit of dental health – this case will revolve around a common oral tumor that we see in dogs. This stresses the importance of having your pet’s teeth fully evaluated which is part of the routine dental cleanings that your veterinarian can perform, especially as your furry friend ages. Countless times (including the following case), I am referred cases of oral tumors that were noted and biopsied by the family veterinarian.

There are many types of oral tumors and they can range in both their local aggressiveness and there ability to spread to other areas and significantly shorten your pets life and diminish their quality of life. The overall prevailing thought is that early detection of an oral tumor can increase the odds of a successful outcome in many cases. Any new nodules/bumps noted in the mouth or along the jaw line or nose should be brought to your veterinarians attention for further investigation.

The case for this month, involves a German Shepherd mix that presented to me for a mass that was noted in the front of the mouth – incisor 1-3 on the right side of the maxilla (upper jaw). This was noted on a routine dental examination and was biopsied before seeing me. (I love it when patients come with the oral mass already biopsied – it removes that first step for me). It is very important that oral tumors are biopsied prior to developing the final surgical plan. The size/extent of the surgery is very dependent on the tumor type – some are less aggressive and require less of an extensive surgery than others. Also, knowing what we are dealing with can help us predict the course of the disease and survival times.

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Figue 1: Picture of the oral mass on the upper jaw.

The tumor’s biopsy results revealed that it was an acanthotamous epulis/ameloblastoma. The epulid tumors come in three varieties with this type being the most common. These types of tumors can behave locally aggressive (invading into the local soft tissue and destruction of the underlying bone), however they tend to not metastasize (spread to other organs). With this type of tumor, because it doesn’t have a tendency to spread elsewhere, the next step is to perform a CT scan of the head to evaluate the extent of the tumor, which guides us in the surgical planning for tumor removal. If the patient has other concerns, a more thorough work-up may be needed (chest evaluation and abdominal ultrasound). A Complete Blood Count/Chemistry profile/Urinalysis is performed prior to an aggressive surgery and anesthetic event.

With these types of tumors, local excision is generally necessary along with removal of the underlying and surrounding bone. This is why it is so important to catch oral tumors early. I have certainly seen these tumors (among others), where they are too big to safely remove, that will still allow the pet to be comfortable and function normally. Luckily for this dog, she was able to do without the front portion of teeth and bone (incisive bone) and this left her with no visual abnormality, once her fur grew back! The last thing that we look at following surgery is our margin assessment, which tells us whether we removed it all and by how much. For this lucky girl, no further treatment was needed!

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Figure 2: Immediately following removal of mass and affected bone/teeth.

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Figure 3: Patient is visually normal following surgery.

 

What’s Your New Year’s Resolve??

What’s Your New Year’s Resolve??

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Ah New Year’s day! The day the gyms are packed with high aspirations, the day that we “turn over a new leaf”, start dieting, develop new relationships, try to find love, etc. We have been at this juncture last year and every January 1st before; many times we were met with the same outcome – disappointment. Not that our “resolutions” weren’t admirable, but we were never quite able to carry them out for a week, month, or let alone a whole year.

I hope this is not the normal New Year’s Day post. As we embark on a new year, we do have a clean slate and can start fresh. While we can restart on any day of the year, January 1st has become the day to reset. I hope everyone can do things differently and better in 2016. This can range from improvement to our health, personal relationships, business relationships, and more. Let’s make our New Year’s resolution one in which we follow out our new found goals! While a common definition of a New Year’s resolution is “a tradition in which a person makes a promise to do an act of self-improvement or something nice”. Wouldn’t it be better if we took a different approach and made goals for the new year and use our “resolve” to accomplish the goal.

A recent definition of the word resolve is “firm determination to do something”. Wow that is powerful, it almost sounds like we WILL accomplish that goal if we show resolve! When making goals we not only need to define what it is we want to achieve, but we need to define the “why we want to achieve it” and the “how we are going to achieve our goal”. The why and the how will fuel and power our resolve. If we never define these important components of our goals, they become mere resolutions and dreams – they are admirable and lofty, but there is no power behind them!

When choosing goals for the new year (or at any part of the year), remember to chose goals that are reachable, defined, and are dependent on you and your actions. I also want world peace, but I also realize there are many factors that go into that dream. Another thought is to WRITE down your goal(s)! Unfortunately, this is a lost art – writing in a journal or notebook. This can be one of the most inexpensive tools, yet one of the most effective tools we can employ. The ability to see our goals in writing can make an immense impact on us and be a constant reminder. Lastly, share your goals with someone you trust and someone that can provide encouragement. Accountability is an essential tool that can power your resolve. For some this may be a spouse, significant other, employer, colleague, parent, etc., whomever this is for you, this can make or break success. You may be thinking that this is a lot of work and you would be correct, reaching goals requires dedication and discipline.

Throughout this new year, let’s continue to make new goals and power them with resolve to follow them out to completion. Remember as we enter a new year, we can put last year behind us, with all the doubts, concerns, and failures – DON’T dwell on the past! Make goals that will better your life and the lives of those around you, both on a personal level and in your business life!

Remember these 4 points:

  1. Write down your goal
  2. Define your why
  3. Define your how
  4. Tell someone

Happy New Year and attack this year with RESOLVE!!!

  • Kevin Benjamino DVM, DACVS
    • Copyright January 1, 2016
When to Consider a Total Hip Replacement???

When to Consider a Total Hip Replacement???

Frankie and Ball

While the thought of a total hip replacement can conjure up thoughts of discomfort, pain and prolonged recovery, most of the time this is not the case. In dogs, total hip replacements have been performed for over 25 years and typically have great success when performed by the experienced surgeon with an experienced team. There are many reasons for total hip replacements in the dog, but the most common reason is as a treatment for canine hip dysplasia.

When considering whether a total hip replacement may be an option for your pet, a consultation with a boarded veterinary surgeon who is experienced in this procedure is the first place to start. Typically your family veterinarian can guide you in this process and make a referral to a surgical center that they trust.  When you are faced with this possible treatment option, you will be overwhelmed with questions and the biggest being, “is this the right thing to do for my pet?” My goal is to try to answer some of the commonly asked questions by owners. While I may be biased since I am a veterinary surgeon, I have also been on the owner side of the equation with my own dog with bilateral hip dysplasia (see Frankie’s Journey).

What are the common indications (reasons) why a total hip replacement would be recommended?

This is one of the biggest questions that I hear and there are actually many reasons that a total hip replacement may be recommended. The most common reason is chronic hip dysplasia. While we see hip dysplasia less than a few decades earlier, we do still see this potentially debilitating disease with some frequency. Hip dysplasia refers to a hereditary issue that induces laxity (looseness) within the hip. This looseness causes subluxation or luxation of the affected hip. Subluxation refers to movement of the femoral head partially out of the acetabulum. Think of a ball and socket joint and the ball(femoral head) is popping out of the socket(acetabulum) with movement. Luxation refers to the femoral head completely coming out of the acetabulum. This alone can cause pain and lameness in puppies and young dogs. In some dogs, they learn to navigate without much discomfort, but the joint will start to develop chronic arthritic changes and cartilage wear that go on to cause pain and discomfort. While we term a total hip replacement an end stage procedure, this just means that in dogs with chronic hip dysplasia and arthritis we always try medical/conservative management prior to surgery. There are dogs that, despite medical management and rehabilitation, are still painful and require surgical intervention; or dogs that need to be on medications continuously for the rest of their lives to be comfortable which would also qualify as a total hip replacement candidate.

Frankie's pre-operative x-rays. Bilateral hip dysplasia.

Frankie’s pre-operative x-rays. Bilateral hip dysplasia.

Other indications for a total hip replacement would include fractures associated with the hip, especially when associated with the femoral head and neck. Traumatic hip luxations are another indication. This is where the hip “pops” out of the joint due to excessive force, such as a dog that has been hit by a car. We do see congenital, chronic hip luxations and acute, non-traumatic luxations, however these cases tend to be at a heightened risk of complications with a total hip replacement. Your surgeon will review the options if your dog has this type of condition. Another indication would be for avascular necrosis of the femoral neck – this is a condition where the blood supply to the femoral neck is altered and reduced during the growth phase. Subsequently the femoral neck and head undergoes cell death (necrosis) which leads to deformation and eventual fracturing. This is more commonly seen in small breed dogs.

What types and sizes of dogs are candidates for a total hip replacement?

We generally think of total hip replacement for larger dogs, which used to be the case. The typical dogs that receive this type are surgery are the retriever and shepherd breeds, since we see hip dysplasia in these dogs more commonly. The standard weights of dogs tend to be 40 pounds and over, however that is changing. With the onset of smaller instrumentation and implants, we now can implant a total hip replacement in a dog as small as five pounds and in some cats.

Isn’t my dog too young for a total hip replacement?

While there are certain age related requirements, there aren’t any exact age requirements. Most of the requirements are based on growth plate closure associated with the femur and in particular the greater trochanter, which generally is closed at around 9-10 months of age (older in giant breed dogs). Some clients will ask, “isn’t my one year old Golden Retriever too young?” My response is “no” if the patient is painful and not responding to the conservative management. The implants themselves have a life span of >15 years, generally exceeding the life expectancy of the pet.

The converse of whether the pet is too young for a replacement is the questions as to whether the pet is too old for the procedure. With older dogs, we need to look at the entire health of the patient and ensure that the patient does not have any other related or unrelated illnesses. Total hip replacements still may be recommended in our geriatric patients.

Frankie's post operative radiographs. Left total hip replacement.

Frankie’s post operative radiographs. Left total hip replacement.

What should I expect on my initial consultation for a total hip replacement?

Every surgeon conducts their examinations differently, so here is a brief overview of a standard consultation that I would perform. Obtaining an accurate history is imperative, so be sure to be upfront with what you are seeing at home, when lameness started, what side is most affected, and ALL medications that your pet may be on or may have tried in the past related to treating lameness.

A full physical examination will be conducted looking at general health, orthopedic and neurologic health. During the general examination we are looking for any other issues that may be just as or more important than your pet’s lameness. Some examples are dental disease (potential infection source), heart murmur/cardiac disease, masses palpated on skin, abdomen or on rectal examination, and skin health. Skin infections (even mild) NEED to be treated prior to surgical consideration due to implants being used.

A full orthopedic exam is needed to rule out any other common orthopedic disease such as cranial cruciate ligament (ACL) tears, medial patella laxations, etc., which may require surgical treatment before considering a total hip replacement. A complete neurologic examination is also needed as neurologic disease would be cause for concern.

Below is a summary of the initial consultation:

– Complete examination

– Sedated X-rays. Most patients (even the best behaved patients) will require sedation for radiographs (x-rays) of the hips. We use these x-rays for measurements of implants, so they must be PERFECT. Remember that the reason your pet is seeing a surgeon is because of hip pain, and the positioning of the x-rays may cause some discomfort, so the kindest way to acquire radiographs is with sedation.

– Blood work: Complete Blood Count (CBC), Chemistry profile, and Urinalysis. This needs to be performed at the MOST 30 days prior to surgery to ensure that your pet is a good anesthetic candidate.

– In older patients, additional diagnostics may be recommended such as chest radiographs and an abdominal ultrasound to get a complete health screen.

Assuming your pet is a good candidate for a total hip replacement the procedure will be described to you in detail along with the potential complications, recovery period/rehabilitation, and overall outcome. If for some reason a total hip replacement is not a good choice or another issue is found, other treatment options will be reviewed in depth. I always mention to owners to allot enough time for the consultation since a lot is performed on that first visit.

Will both hips need a replacement?

Every surgeon may have a differing of opinions on this. My thoughts reflect the more conservative viewpoint of 20% of dogs with disease in both hips, need hip replacements in both hips. We tend to see a large amount of patients compensating very well when one hip is replaced. That being said there are some dogs that do require both be performed. The typical time frame for performing surgery on the second side is about six months (sooner in a small number of patients).

Are there other hip procedures other than a total hip replacement?

There are four main surgeries available for hip dysplasia in the dog. The first two have strict time frame/age requirements. The first is called a Juvenile Pubic Symphodesis (JPS) which is a procedure that fuses a growth plate that allows the acetabulum (cup/socket) to cover the femoral head (ball) better. This must be performed in dogs under 6 months of age, before the growth plate closes on it’s own. The second procedure is called a Double/Triple Pelvic Osteotomy (DPO). This is performed ideally in dogs under 10-12 months of age and prior to development of any arthritis. This procedure improves the coverage of the acetabulum over the femoral head and can be very effective in dogs with subluxation rather than luxations.

The two main surgical interventions for adult dogs with hip dysplasia are the Total Hip Replacement (THR), which is the scope of this article and the Femoral Head Ostectomy (FHO). The femoral head ostectomy is a procedure where the femoral head is removed and not replaced. This removes the painful source of the femoral head as it contacts the surface of the acetabulum. This is performed with a degree of frequency in small breed dogs and cats, but is considered in some cases of larger breed dogs. There are some cases where this procedure is the best option, however it has been seen that overall use and function of the limb is diminished when compared to a successful total hip replacement. In some studies, an unsatisfactory result (decreased range of motion and decreased muscle mass) has been described in as high as 40% of cases where a FHO was performed.

The total hip replacement is a procedure that replaces both the femoral side (femoral head and neck) and the acetabulum. This procedure when successfully performed allows for normal, uninhibited movement of the new hip and generally allows for a full recovery. This procedure has been done in many working dogs (police dogs, service dogs, etc.) in which the dog is able to resume its normal “job”.

Are “cementless” implants better than “cemented” implants?

There are definitely pluses and minuses to both systems. “Cementless” implants are also thought of as press fit and have a surface where the bone grows into the implant. “Cemented” implants are held in place by a polymerizing bone cement and is as strong as it will be once it solidifies and dries. We do see a slightly higher risk of infection around the implants with the cemented implants as well as what is termed “aseptic” loosening. Where the bone anatomy allows, we strive to use the “cementless” implants.

What are the potential risks and complications that could occur after a total hip replacement?

During the initial consultation we always cover potential complications. While the total hip replacement procedure has a high success rate, there are always potential complications. The first type of complication would involve implant complications, which can be exacerbated if the post-operative instructions are NOT strictly followed. Our patients, after all, are dogs and will not regulate their activity appropriately, herein lies the owner’s responsibility. If the patient is too active the more common type of complications are implant shifting, luxation of the hip, fracturing of the femur, femoral stem subsidence, and seroma formation. The first three complication would require another surgery. Other complications could include infection (short and long term), aseptic loosening of the implants, etc.

What is the outcome for my pet after a total hip replacement? 

In general, the outcome for the total hip replacement patient is quite good. Ideally the success rate of total hip replacements in the appropriate patient is around 92-95%. The return of function is typically very good and restoration of normal range of motion and improved musculature. The typical recovery/rehabilitation period is about 3 months in total, however it is a gradual ramping up of activity. As I tell my owners, if I can do it with my own dog, you can do it!!

– Frankie one day after a total hip replacement.

– Frankie (and Vinnie) 1 and 1/2 years after his total hip replacement.

The Importance of Direct Communication

The Importance of Direct Communication

Jacksonville Beach

Now before I get started, I will say that this is a topic that I personally struggle with on a daily basis (ask my wife). The more technology advances the more difficult it becomes to have direct, meaningful communication. Maybe it isn’t more difficult, but the alternative of indirect communication becomes easier and easier. I was walking on the beach recently (where the photo above came from) and saw a couple enjoying the sunrise and the waves. On a closer look (no I am not acting as the creepier version of Rob Lowe on the DirectTV ads) both were fully absorbed in their online life on their cell phones. Maybe they were “liking” that video of a singing and dancing cat, who wouldn’t?! It baffled me to think of coming to the beach for a breathtaking sunrise, only to be checking out Facebook; to each their own.

The real question is how often do we find ourselves, like the beach goers, exchanging quality time that could be spent building a relationship with a loved one, co-worker, or client with increasing our online presence? I am not saying that our online presence is to be ignored, it is a great tool that can help build relationships and improve our marketplace visibility. What I am saying is to be careful that we are not exchanging real relationship building opportunities for our mobile devices. Think of this way, Jon Acuff writes in “Do Over” about being present and gives the following scenario (albeit paraphrased): Each of us have been on the receiving or the giving end of the following scenario, you are in the middle of a conversation and either you or the other party pulls out their phone and scrolls through the contents. Who knows what they are doing, probably checking the weather or “liking” a post from a friend, but whatever it is, they have effectively put you on “pause”. Without speaking a word they have said “hang on a minute, because this is more important than what we are currently discussing”. This scenario happens on a daily basis and I am just as guilty of it as the next person.

The applications can be made to ones personal life, however I will let you formulate your own “real life” examples – I never pretend to be a psychologist. What are the professional correlations? Think of your business relationships (staff and clients) as you would your personal relationships for a minute, both demand time and nurturing or at some point when you look up from your computer or mobile device, they may be gone as well as an opportunity. Remember, the art of personal communication cannot not be captured in a text, email, or hitting “like” on social media; it requires time, attentiveness, and work for both parties involved. So much can be gained by a person’s facial expression and body language that gets missed with the indirect communication described above. In your professional life, try devoting more time to one-on-one direct communication, it WILL payoff!

Kevin Benjamino DVM, DACVS
Copyright @ 2015

Laryngeal Paralysis

Laryngeal Paralysis

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Spring and summer bring about so many good things: the beach, warm weather, family gatherings, to name a few; and then some bad things: bugs, sweltering heat and humidity, allergies, and the list goes on. For your pets, especially your older retrievers and short nosed (brachycephalic) breeds like the pug and bulldog, the heat and humidity can spell danger due to airway conditions. For more information on the brachycephalic dog breathing issues, see my other post  http://wp.me/p2vvxS-2R . This article will focus on a condition called laryngeal paralysis which typically affects our large breed dogs, such as the Labrador Retriever and similar breeds, although it has been seen in cats (rarely) and is a defined disease process in horses.

What is laryngeal paralysis?

Laryngeal paralysis can be as bad as it sounds. The larynx is at the back of the mouth and allows the passage of air into the windpipe (trachea). In the video below, it mimics swinging doors and the cartilages (arytenoid cartilage) that form the larynx will open when breathing “in” (inspiration) and open when breathing “out” (expiration). It remains closed during other actions, like eating and swallowing, thus stopping food, water, saliva from going down the trachea. There is a muscle that controls the opening of these cartilages. The muscle (cricoarytenoideus dorsalis muscle) sits on top of the cartilages on both sides and actively contracts to open the cartilages during inspiration. The opening of the cartilages when exhaling is passive as the air blows open the cartilages. Laryngeal paralysis is a condition where the nerves that feed this muscle are not working properly and the muscle atrophies and is nonfunctional – hence the larynx is paralyzed and can’t move normally.

What causes this condition???

In most dogs, we do not know the reason for this condition. We divide the condition into two general types: 1. congenital and 2. acquired. In congenital, this condition is usually seen at an early age and is thought to be hereditary. Some common breeds affected are Siberian Huskies, Bulldogs, Rottweilers, etc. In the second form (acquired), it simply means that the disease occurs secondary from other issues. When we think of causes we have to ask ourselves, what can cause damage/changes to the nerve (recurrent laryngeal nerve) that feeds the cricoarytenoideus dorsalis muscle? Conditions that we evaluate for typically are as follows: cervical (neck) tumors, chest/lung tumors, myasthenia gravis, peripheral neuropathies, previous neck (cervical) trauma, and endocrine diseases. Most of the time, we do not find a direct cause and suspect an undiagnosed peripheral neuropathy as the underlying cause. When we do not know the actual cause we term the disease “idiopathic”. Some recent studies (Stanley, et al) have shown that most (if not all) patients with idiopathic laryngeal paralysis will begin to display some generalized neurologic signs within 1-2 years following the diagnosis.

What are the signs of acquired laryngeal paralysis???

Typically, this affects our larger breed dogs, with the Labrador Retriever being the poster child for this disease. The dogs affected are generally middle to older in age, and either male or female. The most common signs noticed is difficulty breathing, especially when exercising or excited and gagging/coughing when eating/drinking. This is a progressive disease, so signs usually begin with mild changes and become more severe, which can be over months to years. You may also notice a change in the pitch of your dogs bark (voice). Most of the time, we can arrive at a presumptive diagnosis just listening to your pet breathing. As the disease progresses, the affected dog becomes more at risk, and can have a respiratory emergency if not managed appropriately, which can be fatal. Below is a video (the audio is most important) of a dog with laryngeal paralysis:

What diagnostics are involved with laryngeal paralysis???

To begin, a thorough general and neurologic examination is needed for your pet. At minimum, a complete blood work, including a thyroid screening panel, and chest (thoracic) x-rays are needed. The importance of these is to look for other disease processes that may be going on and to ensure that the major organs are functioning appropriately. Why the thyroid panel? Hyopthyroidism (low thyroid hormone production) can cause various neuromuscular issues. With the chest x-rays we are looking for any masses, changes to the esophagus size (megaesophagus) and signs of aspiration pneumonia, which can be seen secondary with laryngeal paralysis. Because most of the patients I see with this condition are older and we are assessing for surgery, I highly recommend an abdominal ultrasound by an experienced ultrasonographer to look for any other concurrent diseases. Bear in mind, if your pet is in a respiratory crisis some of these steps may be done out of order to adequately stabilize the patient.

The best way to confirm the suspected diagnosis of laryngeal paralysis is to look directly at the larynx and assess the functioning of the laryngeal cartilages. This is typically done by inducing a light plane of anesthesia and looking at the back of the mouth. The proper assessment is sort of an art and takes practice to be comfortable making the diagnosis. In addtion to evaluating the larynx, time is taken to look at the rest of the oral cavity for other potential causes. As a surgeon, my preference is to do this examination directly prior to surgery to minimize the amount times the pet needs to undergo anesthesia.

Below is a video demonstrating laryngeal paralysis. The laryngeal opening can be seen and you will notice that it is not moving much at all during the phases of breathing.

How can I treat my pet once laryngeal paralysis is diagnosed???

Probably the better questions is when do I treat? Once a diagnosis is made, then a decision needs to be made. Since this is a progressive disease, if only one side of the larynx is affected then surgical options will most likely be delayed. The most typical treatment for idiopathic laryngeal paralysis is surgical. To date, there is no medical therapy that will restore the function of the larynx. Conservative management will typically incorporate ways to keep your pet cool (air conditioned environment), sedation possibly, and decreasing environmental allergens. If, during our pre surgical diagnostics, we find other issues, changes may be made to the treatment plan. There are some findings that may make your veterinarian reconsider your pet being a good surgical candidate, such as an enlarged esophagus (megaesophagus). The main reason to proceed forward with surgery is to improve your pets quality of life for however long that may be, as well as improve your (as the owner) life by providing more quality time together. There are risks both with surgery and without surgery.

The standard procedure to open the airway is called an arytenoid lateralization (laryngeal tie-back). This is a procedure that pulls one side of the laryngeal cartilages back, permanently opening one side of the larynx. In effect, we override the normal muscular action of the larynx. We gain access to the larynx by an incision made on the side of the neck. None of the work is done within the mouth. There are other procedures that remove the arytenoid cartilage portion of the larynx to permanently open the larynx from within the mouth, called an arytenoidectomy. This procedure, in my opinion, has not been evaluated as much as the “tie-back” procedure.

Below is a picture of an arytenoid lateralization. Notice the difference on the opening from the previous video.

Tie back

What are the risks with and without surgery and what is the typical outcome?

No procedure is without inherent risks, unfortunately. The risks and benefits of any procedure must always be weighed and discussed with your veterinarian and veterinary surgeon. The most common post-operative complication is aspiration pneumonia. Recent literature cites about a 12-15% risk of aspiration pneumonia following surgery, with the most critical time period being the actual recovery from surgery and the immediate post-operative period. Some medications can be administered that help reduce vomiting, regurgitation and increasing the tone of the lower esophageal sphincter muscle – all aimed at lowering this risk. Most of the time aspiration pneumonia, if caught early, can be treated successfully with antibiotic therapy and supportive care (depending on severity). In a small number of patients, aspiration pneumonia can be fatal. Other complications are break down of the “tie-back” suture and incisional complications such as seroma and abscess/infection. Anesthesia complications can arise with any anesthesia/surgical event, however with proper screening, this risk can be minimized. My feeling is that even dogs prior to a “tie-back” procedure have a higher risk of aspiration pneumonia because the protective mechanism of the larynx is not functioning properly.

Surgically addressing this condition can be life saving and drastically improve the quality of your pets life. Most owners (~90%) are happy they made the decision to proceed forward with surgery and are pleased with the improved quality of life for their pet. If you notice any of these changes to your pet, please plan to see your veterinarian to see if they are a candidate for surgery. While the above article is long, it does not include everything related to this disease, if you have questions, just ask!!!

Kevin Benjamino, DVM, DACVS

Copyright  2015