Laryngeal paralysis Laurent Findji dmv ms mrcvs diplecvs



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Laryngeal paralysis
Laurent Findji DMV MS MRCVS DiplECVS
VRCC Veterinary Referrals, Essex, United Kingdom

Laryngeal paralysis (LP) is a common cause of upper airway obstruction. It is more common in dogs, but occasionally affects cats1-3. It is most frequently an acquired disease, although a congenital form affecting young dogs is well-known and most commonly encountered in Bouviers des Flandres, Siberian Huskies, Dalmatians, English and Staffordshire bull terriers and Rottweilers. The acquired form affects older dogs, most commonly of large breeds. In many studies of acquired LP, Labrador retrievers were the most frequently affected breed4-18.


Anatomy19, 20


The larynx mainly consists of 4 cartilages: the epiglottic, arytenoid (paired), thyroid and cricoid cartilages (Figure ). These cartilages are united by joints (fibrous or synovial) and muscles. The combined actions of intrinsic laryngeal muscles on these cartilages modify the size, shape and position of the glottis, rostral opening to the (infraglottic) laryngeal lumen and trachea. All intrinsic laryngeal muscles except the cricothyroid, which is innervated by the cranial laryngeal nerve, are innervated by the caudal laryngeal nerve, terminal segment of the recurrent laryngeal nerve (RLN). The RLN originates in the thorax from the vagus nerve and courses cranially up to the larynx, dorsolaterally to the trachea.

Figure : Anatomy of the larynx, lateral and cranial views (1: Cricoarytenoid joint; 2: Cricothyroid joint)


Physiopathology


The larynx keeps the entrance to the trachea. At rest, the passageway through the glottis, called rima glottidis, is narrow. On inspiration, the rima glottidis is made larger mainly by the action of the cricoarytenoideus dorsalis muscle, which rotates the arytenoid so that its vocal process moves laterally (Figure ). When swallowing, the rima glottidis is made narrower by the combined action of several intrinsic laryngeal muscles (cricoarytenoideus lateralis, thyroarytenoideus, ventricularis and arytenoideus transversus). In addition, when swallowing, the hyoid bone and pharynx are pulled rostrally, which brings the rima glottidis under the lifted epiglottis. The epiglottis then completely covers the narrowed rima glottidis, thereby preventing the passage of ingesta through the larynx into the trachea.

Figure : Schematic representation of the laryngeal function (A: Rest; B: Abduction)

Laryngeal paralysis results from disease of the recurrent laryngeal nerve(s). The origin of this disease is unknown in most cases of acquired LP, which is then called idiopathic. Neoplasia, trauma, infection or complications from cervical or thoracic surgery have however been reported as infrequent causes of LP. In idiopathic LP, the RLN disease is progressive, non-inflammatory and degenerative21. More and more evidence exists indicating that LP may be an early sign of a generalized neuromuscular disease rather than an isolated condition4, 5, 8, 22. A study of 11 dogs with acquired LP confirmed that these dogs were polyneuropathic through electrodiagnostic and histopathological examinations4. This underlying polyneuropathy is of great clinical relevance as, in the same study, neurological clinical signs progressed in 8 of the 9 dogs during the follow-up period (16 months or more)4. Another study revealed that dogs with idiopathic LP also suffered from oesophageal dysfunction, and that the more severe this dysfunction, the higher the risk for aspiration pneumonia5. In this study, 24 dogs could be followed over 12 months. Neurological clinical signs were observed in 25% of them at enrolment, whereas such signs were found in 58% and 100% of these dogs at 6 and 12-month follow-ups respectively5. At 12 months, the neurological signs observed were slight ataxia and weakness, with proprioceptive deficits in 17% of dogs, obvious ataxia, muscle atrophy and weakness in 38% of dogs, marked paraparesis in 42% and non-ambulatory paresis in 4% of dogs5. The cause for such generalised polyneuropathy remains unknown in most cases, although hypothyroidism, diabetes mellitus and myasthenia gravis have been found to infrequently cause LP. Several studies provide evidence that LP can result from a “dying-back” neuropathy, in which the most distal portion of axons degenerates first4, 8, 23. This could explain why LP would be an early sign of the generalised neuropathy, as the RLN, being a very long nerve, should be more susceptible to dying-back neuropathies than shorter nerves. However, this has not been demonstrated histopathologically4 and it has also been suggested that many different types of generalised neuropathy could cause idiopathic LP8.

Regardless of its cause, RLN dysfunction results in the paresis or paralysis of all intrinsic laryngeal muscles except for the cricothyroid muscle. On inspiration, the arytenoids are not actively rotated and the rima glottidis remains narrow, which cause upper airway obstruction. When swallowing, the rima glottidis is not narrowed, which increases the risk of aspiration pneumonia24. Vocalisation is also affected, as the muscles responsible for tensing and relaxing the vocal folds are weak or paralysed.


Diagnosis


Laryngeal paralysis is essentially a clinical diagnosis, later confirmed by other investigations. When using laryngoscopic observation as the gold standard for diagnosis of LP, clinical suspicion appeared very sensitive (91.6%) and specific (98.5%) for severe LP25. Early clinical signs are a change in phonation, inspiratory stridor and exercise intolerance. Gagging, coughing and retching, as well as vomiting/regurgitations and dysphagia may also be reported. Later in the course of the disease, dyspnoea, respiratory distress, cyanosis and syncopes may be observed. In addition, hyperthermia is frequently observed in dogs with LP, of which it can be a life-threatening consequence. It results from the increased work from the ventilatory muscles and decreased heat dissipation because of the impaired airflow secondary to the airway obstruction26.

Once a suspicion of LP has been raised, it can be confirmed in several ways. The most common is direct or videoscopic transoral observation of the larynx under light general anaesthesia. Most anaesthetic agents reduce laryngeal movements, which can mimic laryngeal paresis / paralysis. The influence of several anaesthetic protocols on laryngeal motion have been evaluated in normal dogs 27: associations of acepromazine + thiopental, acepromazine + propofol and ketamine + diazepam resulted in no laryngeal motion in 67%, 50% and 50% of dogs, respectively, and were not recommended. Greater arytenoid motion was observed with thiopental used as a single agent. When dogs were premedicated with acepromazine or opioids, mask induction with isoflurane was recommended to minimise laryngeal motion inhibition. Alternatively, intravenous administration of doxapram (2-5 mg/kg) can be used to increase respiratory motion10, 27, 28. However, in dogs with LP the use of doxapram can result in increased paradoxical motion of the arytenoids and respiratory distress, which can mandate prompt endotracheal intubation10. Paradoxical laryngeal movements can be observed in animals with LP. They consist of narrowing of the rima glottidis on inhalation, as a result of the negative pressure caused by the airflow through the narrow laryngeal ostium (Bernouilli effect), and “opening” of the rima glottidis on exhalation as a result of air pressure. It is therefore critical to determine how laryngeal and respiratory movements are coordinated to avoid misdiagnosis.


Other diagnostic tests have been reported: electromyography, ultrasonography14 and transnasal laryngoscopy11. A recent study comparing ultrasound, transnasal laryngoscopy and laryngoscopy per os concluded that ultrasound was less effective in diagnosing LP than the other two methods because of the difficulty in differentiating normal from paradoxical laryngeal movements29. No significant difference was found between transnasal laryngoscopy and laryngoscopy per os. Being less risky to perform, laryngoscopy per os was the recommended method29.

Diagnostic tests aiming at screening for concurrent diseases are also carried out: haematology, blood biochemistry, thyroid function exploration and acetylcholine receptor antibody titres (myasthenia gravis). Thoracic x-rays are also recommended to rule out pre-existing aspiration pneumonia and other concurrent diseases which could affect the prognosis, such as megaoesophagus.


Treatment


For dogs presented as an emergency for respiratory distress, the initial treatment includes oxygen supplementation, steroidal anti-inflammatories (e.g. dexamethasone 0.1-0.3 mg/kg) and sedation (acepromazine 0.05-0.1 mg/kg). Sedation is contraindicated in dogs with decreased thoracic compliance because of concomitant intrathoracic disease. When administered, sedation will improve breathing by reducing the respiratory efforts, thereby minimizing airflow velocity and associated Bernouilli effect. Sedation will also facilitate resolution of the potential hyperthermia shown by dogs with LP. Most dogs can be stabilised with such treatment. When insufficient, endotracheal intubation and surgical correction of the LP or temporary tracheostomy must be carried out promptly.

Several techniques of surgical correction of laryngeal paralysis have been described including ventriculocordectomy, partial arytenoidectomy, arytenoid lateralisation, (modified) castellated laryngofissure, combinations thereof and permanent tracheostomy6, 7, 18, 30-34. Currently, only two types of techniques are commonly used: arytenoid lateralisation techniques and partial laryngectomy techniques. Partial laryngectomy techniques are most commonly performed transorally and carry the risk of specific complications resulting from associated intralaryngeal trauma including blood aspiration, oedema, haematoma and laryngeal webbing. Such complications may however be much less frequent when the arytenoidectomy is performed using a diode laser6. To avoid intralaryngeal trauma, unilateral arytenoid lateralisation techniques are often preferred to partial laryngectomy techniques. In particular, unilateral arytenoid lateralisation (UAL) is considered by many surgeons as the treatment of choice7, 35-37, as it appeared associated with fewer complications than bilateral arytenoid lateralisation and partial laryngectomy15. It has our preference and will be the only treatment described here. Descriptions of other treatment modalities can be found elsewhere21, 26, 38.



When preparing the patient for a UAL, a smaller than usual endotracheal (ET) tube is used for maintenance of anaesthesia. Endotracheal intubation results in arytenoid abduction prior to surgical correction and too large a tube will favour excessive lateralisation at surgery. For a lateral approach, the animal is placed in lateral recumbency and a cushion can be placed under its neck to elevate the laryngeal area towards the surgeon. The skin is incised over the larynx, ventrally and parallel to the external jugular vein. The subcutaneous connective tissues and cutaneous muscles (sphincter colli superficialis, platysma and sphincter colli profundus) overlying the larynx are reflected by a combination of blunt and sharp dissection. The thyropharyngeus and cricopharyngeus muscles are then visible and the dorsal border of the thyroid cartilage lamina is palpable through them. Rather than transecting the thyropharyngeus muscle transversely, we prefer to separate its fibres by blunt dissection over the middle of the dorsal edge of the thyroid cartilage. The separated fibres are then retracted with blunt Gelpi retractors, which provides enough exposure of the thyroid cartilage lamina, covered by a fascial membrane. This laryngeal fascial membrane is incised and the laryngeal mucosa is detached from the medial aspect of the lamina of the thyroid cartilage. This is done by combination of scalpel incision over the dorsal edge of the thyroid cartilage and blunt dissection with a Freer periosteal elevator or cotton-buds. Dissection is performed delicately to avoid perforation of the laryngeal mucosa and penetration into the lumen of the larynx. In addition, dissection is limited cranially to avoid damage to the cranial laryngeal nerve, which carries fibres supplying the sensory information from laryngeal mucosa. Preserving these fibres may minimise the incidence of postoperative aspiration of food13, 39. The lamina of the thyroid cartilage is retracted laterally using one stay suture. Disarticulation of the cricothyroid joint is not necessary for sufficient exposure of the arytenoid cartilage. Furthermore, it may reduce the diameter of the rima glottidis after arytenoid lateralisation40 and disrupt the lateral support of the larynx, which makes the larynx more prone to collapse dorsoventrally41. Another study showed no effect of the disarticulation of the cricothyroid joint or section of the interarytenoid sesamoid on the area of the rima glottidis42. These techniques did not have a significant effect on laryngeal airflow either42 and are therefore left to the surgeon’s discretion. The muscular process of the arytenoid is palpated and the cricoarytenoideus dorsalis is transected just caudally to it. The caudal part of the cricoarytenoid joint capsule is incised, but its rostral part is left intact to limit the later abduction of the arytenoid37. I do not section the interarytenoid structures (interarytenoid “band”) in order to minimise the laryngeal disruption and decrease the risk of mucosal perforation. One or two “simple interrupted” sutures are placed between the dorsolateral aspect of the cricoid cartilage and the muscular process of the arytenoid cartilage (Figure ). Placement of the suture through the cricoid cartilage is done in a caudo-rostral direction. The caudal border of the cricoid cartilage is only palpated: dissection aiming at visualising it is unnecessary. Alternatively, a thyroarytenoid suture may be used by placing the suture through the caudo-dorsal portion of the lamina of the thyroid cartilage. The use of thyroarytenoid sutures instead of cricoarytenoid sutures results in a lesser increase of the rima glottidis area, but is shorter to perform and is associated with a similarly satisfactory outcome16. It has however been shown to be less effective in improving the laryngeal airflow in isolated canine larynges42. Subjectively, it is less technically and may be preferred by surgeons with little experience. In the arytenoid cartilage, the suture is passed medio-laterally. Along the rostro-caudal axis, both sutures are placed in the middle of the arytenoid articular surface. Along the ventro-dorsal axis, the two sutures are evenly spaced, at the ventral and dorsal third of the arytenoid articular surface43. The sutures are tied but not excessively tightened, as low-tension sutures have proved equally efficient in decreasing airway resistance37 and decrease the portion of the rima glottidis remaining uncovered when the epiglottis is closed44. In doubt, an assistant may extubate the animal and control transorally that the arytenoid abduction is satisfactory. The lamina of the thyroid cartilage is released, the thyropharyngeus muscle fibres are apposed in a cruciate pattern and the wound is closed routinely. If it has not been assessed intra-operatively, the arytenoid abduction is controlled postoperatively by transoral visualisation.

Figure : Schematic representation of the placement of


a cricoarytenoid suture without disruption of the cricothyroid joint

Prognosis


In dogs without clinical signs of concurrent disease, the prognosis after UAL is good: in one study in which dogs with swallowing or neurologic abnormalities were excluded, 91% of dogs were considered to have had a very satisfactory outcome 1 year after surgery and complications were only observed in 10% of cases18. In another study, postoperative complications were observed in 31 of 109 dogs (28%) which underwent UAL, 21 (19%) of which were aspiration pneumonia15.

However, as described above, most affected animal suffer from generalised neuromuscular disease, which is the main determinant of their long-term prognosis. In one study, 6 of 11 dogs with acquired LP died or were euthanized within 15 months of diagnosis as a result of progression of clinical signs associated with their polyneuropathy4. Although neurological signs are likely to worsen over time, the polyneuropathy may progress slowly and long remain compatible with a reasonable quality of life. Therefore, in spite of this permanent risk of neurological deterioration, seeking surgical treatment for LP is appropriate to address the respiratory obstruction, which can be life-threatening in the short-term.



Aspiration pneumonia is the most commonly described complication after surgical treatment for LP. After unilateral arytenoid lateralisation, it has been reported to occur in 8 to 19% of cases5, 9, 12, 13, 15, 16. Aspiration pneumonia can occur months to years after surgery and operated dogs remain are at risk for the remainder of their lives5, 9, 12, 15, but it seems that the risk decreases over time9, 12, 35. Perioperative administration of metoclopramide may lower the risk of aspiration pneumonia45. In addition, if owners are given clear instructions of monitoring, aspiration pneumonia can often be detected early and respond favourably to treatment5.
Other commonly reported complications after UAL include persistent coughing and gagging (16-28%)9, 12, surgical repair failure and recurrence of clinical signs (0-8%)12, 13, 15, 18, persistent exercise intolerance (23%)9 and seroma requiring drainage (3-10%)9, 18.

Laryngeal paralysis in cats


Laryngeal paralysis is much less common in cats than in dogs. Like in dogs, laryngeal paralysis appear to be either congenital or acquired in cats2, 21. Clinical signs are rather similar in the two species, although cats seem to be only rarely be hyperthermic on presentation3. In case of unilateral LP, cats seem more prone to show clinical signs than dogs with unilateral LP2. Similarly to dogs, acquired laryngeal paralysis may be associated with more generalised neuromuscular diseases: in one study of 16 cats with LP, 2 were found to have concurrent megaoesophagus3 and in a study of 4 cats with LP, signs of a generalised neuromuscular disease were observed in 246. Several techniques have been used for surgical treatment of LP in cats, including ventriculocordectomy, partial arytenoidectomy, arytenoid lateralisation and castellated laryngofissure21. Like in dogs, we prefer low-tension unilateral arytenoid lateralisation, performed following the technique described above for dogs. Whereas it seems associated with few complications in dogs (but is, in our experience, unnecessary), disarticulation of the cricothyroid joint and interarytenoid band is not recommended in cats. Respiratory tract cartilages are much more fragile and friable in cats compared with dogs and the procedure is therefore more demanding in this species: great care must be taken no to fracture the laryngeal cartilages while grasping them or passing needles through them. Cutting needles should therefore be avoided. If such fractures happen intra or postoperatively, a contralateral intervention may be necessary. The incidence of postoperative aspiration pneumonia seems to be much lower in cats compared with dogs3, except when arytenoid lateralisation is performed bilaterally2. Bilateral arytenoid lateralisation is therefore not recommended in cats2.

References


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L. Findji – Laryngeal paralysis – AMVAC 2013

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