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Frankie’s Journey: Part 2

Frankie relaxing before surgery.

After the diagnostics were performed (reviewed in the previous segment), a decision needed to be made as to which issue was to be addressed first. This is often a tough decision and must be made with the experience of your trusted veterinarian. My criteria consisted of which leg was most affected and the fact that I had already decided to address his hips with a total hip replacement. In my opinion (and supported clinically), a total hip replacement was a better option than other procedures available for canine hip dysplasia. Certain growth plates (centers of bone growth) need to be closed prior to performing a total hip replacement making the minimum age being around 10 months of age. This made our decision easier and the decision to address the elbows was made.

Surgery for his elbows was staged; the left elbow surgery performed on December 6, 2013 and the right elbow addressed on February 14, 2014 (Happy Valentine’s Day!). The time period in between was used for physical therapy and maximizing the results of the surgeries. Identical surgeries were performed on both elbows due to the similarity of the disease process occurring. An elbow arthroscopy was performed, which revealed the cartilage flap (osteochondritis dissecans (OCD)) and a fragmented coronoid process (FCP) The OCD flap was removed and the FCP segment was removed. The damaged bone under the OCD flap was removed with a shaver until healthy bone was present. Since the diseased area of the elbow was on the inside (medial) aspect a specialized procedure to displace weight to the central and outside (lateral) aspects was performed. This procedure is called a sliding humeral osteotomy (SHO). This procedure is fairly aggressive and involves a bone cut in the middle of the humerus bone and a plate/screws placed.

Below are images of the elbow arthroscopy showing both the OCD lesion and the FCP segment.

 

Noted the line in the cartilage outline a fragmented coronoid Process (FCP).

Noted the line in the cartilage outline a fragmented coronoid Process (FCP).

Note the underlying bone (pink). This is usually covered by cartilage, however the cartilage has become a flap.

Note the underlying bone (pink). This is usually covered by cartilage, however the cartilage has become a flap.

 

Following the elbow arthroscopy, the SHO procedure was performed. Below is a radiograph of the procedure.

Note the cut in the middle of the humerus and the shifting of the bone.

Note the cut in the middle of the humerus and the shifting of the bone.

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Frankie’s Journey: Part 1

Frankie and Vinnie relaxing.

Frankie and Vinnie relaxing.

Here are some of the diagnostics  that were performed on Frankie. As mentioned before, during his first visit a thorough examination was performed, which revealed congenital issues on all limbs. Also, when he presented he was overweight (for a 6 month old puppy). We do know that too rapid growth and obesity at a young age can preferentially express the genes responsible for these issues and exacerbate signs.

Here are his physical exam findings: lameness noted in all limb, more pronounced on his left side. Pain on hyperextension and hyperflexion of both elbows and pain on palpation of the medial (inside) compartment of both elbows. Pain on hyperextension and hyperflexion of both hips. Positive Ortolani tests on both hips – this is were the femoral head portion of the hip can be pushed out of the acetabulum (socket) and then falls back in; I have downloaded a video displaying this on Frankie.

Our first steps in diagnosis was to perform radiographs (x-rays) and a CT scan of the elbows. The x-rays confirmed both elbow dysplasia and hip dysplasia. Interestingly, Frankie had bilateral Osteochondritis Dissecans lesions, which isn’t commonly seen, but can be a part of elbow dysplasia.

The CT scan demonstrates the same lesions as the x-rays, but gives a different view. A CT scan is a very sensitive diagnostic test for elbow pathology, especially in cases that have not developed normal x-rays changes yet.

Left Elbow: Osteochondritis Dissecans (OCD).

Left Elbow: Osteochondritis Dissecans (OCD).

Lateral view of the left elbow: elbow dysplasia
Lateral view of the left elbow: elbow dysplasia

Bilateral Hip Dysplasia
Bilateral Hip Dysplasia

OCD lesion seen on the humerus.
OCD lesion seen on the humerus.

Fragmented medial coronoid process.

Fragmented medial coronoid process (FCP).

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Pets and Decorations Don’t Mix

A timely discussion about some of the hazards that may be around the home during the holiday season.

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Brachycephalic Obstructive Airway Syndrome – Treatment

Elongated soft palate

Elongated soft palate

Shortened soft palate

Shortened soft palate

The mainstay of treatment for BOAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation. Typically medical management is used after (and in conjunction with) surgical management.

There are many questions that arise when considering surgical management and one of the biggest is when do you consider surgery? BOAS can be seen even in puppies and it is recommended that an evaluation be performed in dogs that are predisposed to this condition. Early management can halt or delay the progression that is typically seen, especially laryngeal collapse.

There are various methods to widen the nares(nostrils). The most common technique is the vertical wedge resection, where a wedge of tissue is removed with the apex of the triangle at the dorsal surface. An absorbable suture can be placed to control bleeding. It is important to make sure that the nares is wide enough to increase airflow.

An elongated soft palate is one of the most common features of BOAS. The assessment and skilled resection is key. If too much is removed, then there is a communication between the oropharynx and nasopharynx. If not enough is removed then the problem still exists.  The most common technique employed is resection with metzenbaum scissors and suture. Sharp excision of the soft palate generally ensures the least amount of inflammation. Other methods, such as CO2 laser and Ligasure, have been described and can be successful. Complications that can arise are as follows: bleeding, inflammation, chronic granulation tissue formation, and further elongation of the soft palate over time.

As mentioned previously, the presence of everted saccules characterizes the patient with stage I laryngeal collapse. There is some controversy as to whether or not everted saccules should be addressed surgically.

With patients that have grade II and III laryngeal collapse surgical correction is more difficult. When collapse is present it is always recommend to correct what is correctable, however the larynx will never be functional again. Some propose modified laryngeal tieback procedures with mixed outcomes. A permanent tracheostomy becomes a very viable option. By performing a permanent tracheostomy the entire upper airway is by-passed.

When counseling owners, generally dogs affected with BOAS have a favorable prognosis. Success is solely dependent on progression of disease. Education of owners should start when the patient is a puppy to avoid worsening. When a patient progresses to laryngeal collapse prognosis decreases greatly, as well as hospitalization time.

 

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Brachycephalic Upper Airway Syndrome (BUAS) – diagnosis

Diagnostic testing:

In addition to direct visualization of structures it is wise to evaluate both the neck and chest. This is most commonly performed with radiographs (X-rays). Structures to evaluate include the oro/nasopharynx, trachea, lungs (for pneumonia, etc), and cardiac disease. If cardiac disease is suspected due to auscultation and radiographs, an echocardiogram is recommended. A complete blood count (CBC), chemistry and urinalysis should be performed prior to anesthesia to assess total body function and if your pet is a good anesthetic and surgical candidate.

A very important part of the diagnostic workup performed just before surgery is the oral examination. One way to evaluate the upper airway is endoscopy of both the larynx and esophagus. This will provide a very thorough evaluation of the soft palate, ventricles and laryngeal function.

Direct visualization is the most common way of diagnosing the associated factors of the brachycephalic dog. The nares are narrower than a normal dog and the airflow is distorted.  For a sedated oral exam, the patient is typically anesthetized (light plane of anesthesia). Evaluating the laryngeal function in these dogs is very important in differentiating laryngeal paralysis from laryngeal collapse.

The mainstay of treatment for BUAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation.

 

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Golden Retrievers Provide Comfort for Citizens of Newtown

Golden Retrievers Provide Comfort for Citizens of Newtown.

This is such a touching story, so I choose to share this as it is animal related. It really demonstrates the bond that we have with our pets and how much influence they really have!!

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Brachycephalic Upper Airway Syndrome (BUAS) – physical exam

Most commonly the history of patients with BUAS are very similar. Generally, owners notice snoring and gradual progression of inspiratory stridor. Many times this will occur while the patient is a puppy and continue into adulthood. Other signs that are noted are increasing frequency of dyspnea especially during exercise or a hot environment. Another sign to look for in addition to the other is vomiting and/or regurgitation. This can be a compounding problem as it predisposes the pet to aspiration pneumonia.

On physical exam one of the first things that can be directly visualized is the nares being stenotic. The observant examiner will also note an increased upper respiratory noise with inspiratory stridor on auscultation(listening with a stethoscope. Typically the rest of the general physical examination is within normal limits.

Prior to performing a sedated oral exam various differentials should be on the list and should include neoplasia (oral/pharyngeal masses/cancer), tracheal collapse, laryngeal paralysis, lower airway disease and cardiac(heart)disease. Both lower airway diseases and cardiac disease can greatly exacerbate upper airway signs and if the patient is stable, these should be addressed first or at least concurrently.

Our next segment will be an overview of the surgical treatment and then we can wrap up this topic.

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Happy Holidays

I want to take a moment to thank everyone for their continued interest and support of this blog. Your continued support has meant a lot to me and allowed me to continue to post various topics. I want to wish everyone Happy Holidays during this joyous time of the year! I wish you all the best in the New Year too! Keep your pets safe throughout this time, but definitely spoil them (we want them to ring in the New Years without any ailments)! Please continue to follow this blog!

Seasons Greetings!!

Kevin

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Brachycephalic Obstructive Airway Syndrome (BOAS)

What makes up BOAS? The most common components of this disease are both stenotic nares(nostril) and an elongated soft palate. These two features are commonly seen. Other components are everted saccules, hypoplastic trachea, and secondary laryngeal collapse. In dogs that have stenotic nares the cartilage that makes up the nares is generally thicker and more condensed and oftentimes more medially displaced which causes an obstruction. Also, the conchae(cartilage in the nasal passageway) can be altered and displaced causing further airway turbulence and obstruction.

Anatomically the soft palate is just caudal(behind) to the hard palate and further divides the nasopharynx from the oropharynx (nasal passage from the mouth or oral cavity). In the normal patient the soft palate will typically extend caudally to just touch (slightly overlap) the epiglottis. In patients with an active obstruction this can be seen to extend 1-2 cm (or more) past the epiglottis. Due to this extension past the epiglottis, this tissue can actively obstruct airflow into the larynx and also become edematous(swollen) and undergo inflammation. Inflammation from this airway obstruction can extend to the tissue surround the pharyngeal region.

Generally considered to be a secondary side effect of the aforementioned conditions, everted saccules can develop due to the presence of increased air pressure of a prolonged period of time. Laryngeal saccules are normal out-pouchings noted adjacent to the vocal folds. Normally they extend outward away from the airway. After being under constant negative pressure these out-pouchings will evert and extend into the caudal laryngeal lumen causing an obstruction. Another secondary effect noted due to the constant high pressure is laryngeal collapse. This generally occurs in later stages of the disease process and will progress in severity. There is a grading scale that is used to assess the condition. Grade I laryngeal collapse is present when the laryngeal lumen is narrowed by everted saccules. Grade II collapse is characterized by both everted saccules and the cuneiform processes begin to collapse inward and fail to abduct during inspiration. Grade III collapse is characterized by the addition of the corniculate processes inwardly folding during inspiration, which signifies complete collapse.

The next posting will go over some of the physical exam findings and what we can do to help these patients out for the long run.

Note the narrow nostrils.

Note the narrow nostrils.