Page 647 - WSAVA2018
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cavity exposure is key to adequate visualization and instrumentation.
In ventral recumbancy, the maxillary canine teeth are hooked over the bar of an ether stand. The mandibular canine teeth are then taped to the operating table in such a fashion that the mouth gapes open. The tongue is grasped with tongue forceps and gently pulled from the mouth.
Surgical technique: The surgical technique varies depending upon the defect to be repaired.
Stenotic nares: This technique is illustrated on the Respiratory Surgery I DVD available via www.videovet. org.
Stenosis is decreased by removing a horizontal wedge of alar cartiladge from the wing of the nostril. The flap created is sutured to remaining tissue of the wing of
the nostril using 3-0 or 4-0 Dexon or Vicryl in a simple interrupted suture pattern. Two or three sutures is all that is generally required to complete the nasoplasty.
An alternate technique gaining popularity in Shih Tzu and Boston breeds is to completely excise the alar cartilage. Bleeding is controlled by wedging a gauze sponge in the patients nostril for 5 minutes by the clock.
Presurgical temporary tracheostomy?: Use of a presurgical tracheostomy facilitates exposure and visualization of the soft palate and laryngeal saccules. However, it is not necessary in the majority of patients. The author considers use of a tracheostomy in patients that present with severe clinical signs (i.e., cynosis, syncope) and have a combination of defects to repair. Tracheostomy is preferred over exiting the endotracheal tube through a pharyngostomy as the tracheostomy can be used in the postoperative management of the patient if necessary. In our hospital, regardless of the severity
of the airway obstruction, the patient is recovered in a critical care environment and instruments necessary to perform an emergency tracheostomy are readily available.
Elongated soft palate: This technique is illustrated on the Respiratory Surgery I DVD available via www.videovet. org.
The patient is placed in ventral or dorsal recumbancy with the mouth opened widely (see positioning). A
broad malleable retractor is used to retract the tongue caudally; this greatly facilitates visualization of the soft palate and laryngeal structures. A headlamp facilitates visualization but is not necessary. Since postoperative edema and swelling are of major concern following soft palate surgery, it is important to keep surgical trauma to a minimum. Use of clamps and electrocautery may cause excessive surgical inflammation and should be avoided. The soft palate is evaluated for extent of resection. A Babcock or Allis tissue forceps is used to grasp the
caudal margin of the soft palate. The length of the soft palate in relation to the tonsil and epiglottis is examined. The soft palate should extend no further caudal than the midpoint of the tonsil. Alternately, the incision is made at the point where the soft palate just slightly overlaps the tip of the epiglottis.
Once this line of excision is determined, a 3-0 or 4-0 Dexon, Polysorb or Vicryl stay suture is placed in the soft palate on each lateral margin of the proposed excision. A third stay suture is placed on the margin of the central portion of the soft palate. The incision is begun from the left or right margin and one-third to one-half of the soft palate is incised.
Using the long end of one of the 3-0 or 4-0 Dexon, Polysorb or Vicryl stay sutures, the incised nasal mucosa is sutured to the incised oral mucosa using a simple continuous suture pattern. Dexon, Polysorb or Vicryl is chosen because of its soft supple nature; Maxon, Biosyn or PDS are much to stiff and may cause irritation to the oral cavity. Hemorrhage is controlled by suture pressure. No attempt is made to cauterize or clamp bleeding vessels. When the palate excision and suturing are complete, the stay sutures are cut and the remaining soft palate replaced and evaluated once again for extent of resection.
Everted laryngeal saccule resection: There is some suggestion that if the stenotic nares and elongated
soft palate can be successfully treated (see above), the lateral saccules will return to their normal location in the larynx and no longer cause airway obstruction without the need for surgical resection. The author only removes lateral saccules in patients that present with severe respiratory signs (i.e., severe cyanosis, syncope).
When removing laryngeal saccules, the patient is placed in dorsal recumbancy with the mouth opened widely. Everted laryngeal saccules appear as edematous, translucent tissue balls lying in the ventral aspect of the glottis and obscuring the vocal folds.
Surgical removal is performed using a sharp long- handled laryngeal cup biopsy forceps (or similar long handled biopsy instrument) or a long handled Allis tissue forceps and #15 BP scalpel blade. If a laryngeal cup biopsy forceps is used the everted saccule is grasped and amputated with the biopsy forceps. Any remaining tags are grasped with a long-handled DeBakey forceps and trimmed with a #15 BP blade or scissors. If an Allis tissue forceps is used the laryngeal saccule is grasped with the Allis forceps and a long-handled scalpel with a #15 BP blade is used to excise the saccule at its base.
If the patient had a tracheostomy tube placed prior to surgery, the saccules are easily visualized and excised as described above. If the patient has an endotracheal tube exiting the laryngeal apparatus, the tube is temporarily removed while the saccules are excised.
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