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Med/Surg Exam IV

Med/surg Exam Iv

by c.a.childs9, May 2014

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	4 magic questions of Neoplasia	1. What is it? --biopsy/aspirate 2. Where is it? --how invasive? 3. What happens if I do something? 4. What happens if I do nothing?
	Nasal Disease	-Most of the nasal disease is encased in bones of the nose
	Nasal Anatomy	-Nasal planum -Nostrils -Nasal vesticule -Nasal cavities -Frontal sinuses -Philtrum: middle of the nose
	Nasal turbinates	-Maxillary turbinates from maxillary bone -Ethmoid turbinates from ethmoid bone --separates the nose from the brain/cranial cavity
	Frontal sinuses	-usually 3 on each side, 6 total -When nasal disease is bad enough the sinuses merge or are destroyed, so number does not matter
	Nasal Disease diagnostic Evaluation	-History: --duration --response to medication --type of discharge --Seasonality --pain -Physical Exam: --symmetry, patency of nasal passages --retropulsion of the eyes? --dental disease --Pharynx exam
	Facial swelling and nasal disease	-Cancer is at the top of the list -Make sure there is airflow through both nostrils -Nasal tumors can erode through the palatine bone and break through the roof of the mouth
	Tooth roots and nasal disease	-Tooth roots have bone around them -If tooth root is eroded away, will erode into the nasal cavity -Can cause chronic nasal disease --oro-nasal fistula
	Diagnostic tests for Nasal Disease	-CBC, chem screen -Radiographs, CT scan -Rhinoscopy -Biopsy, histopathology, culture -Exploratory surgery
	Nasal Radiographs	-Use non-screen film -Put in sealed envelope, shoot down into mouth --only want to look at nose, not rest of the head -Look for symmetry
	Nasal neoplasia on radiographs	-Loss of bony detail on affected side -Homogenous soft-tissue mass -Cancer destroys the turbinates and replaces with soft-tissue density cancer
	Nasal CT	-Gives more detail -Can see deviated septum that is completely normal --do not fix
	Nasal scoping	-Retroflexed view: look at nose from the back -Put scope into ventral nasal meatus --need pressurized fluid in case starts to bleed
	Nasal Biopsy	-Biopsy anything found on nasal scope! -Do not go beyond the medial canthus of the eye, right where the cribriform plate is -Nasal biopsies bleed quite a bit -Need a biopsy to figure out what anything is
	Causes of Epistaxis	-Neoplasia --squamous cell carcinoma
	Canine Viral Rhinitis	-Distemper is most common etiologic agent -Unvaccinated or poorly vaccinated puppies -Occulonasal discharge -Coughing -Pyrexia -Conjunctival scraping for distemper inclusions -Will have subsequent CNS signs
	Feline Viral Rhinitis	-Feline herpes and calicivirus -Vaccination often generates incomplete immunity -Transmission via direct contact with infected cats --limited aerosol transmission -Chronic carrier state, especially if cat is FeLV or FIV positive
	Feline Viral Rhinitis diagnosis	-Signalment, history, clinical signs -Rule out nasopharyngeal polyp -Immunofluorescent staining of conjunctival scrapings
	Feline Viral Rhinitis Treatment	-Supportive treatment with IV fluids, nutrition, antibiotics -No effective antiviral agents
	Bacterial rhinitis	-Rarely if ever primary -Usually due to underlying disease --viral, obstructive, neoplastic, dental, foreign body -Antibiotic therapy should be based on results of culture and sensitivity -Cats with chronic non-responsive rhinitis can have rhinotomy performed
	Cat with chronic bacterial rhinitis	-Turbinates are "melted away" -middle of nose is a "sea of pus" -Do rhinotomy
	Dog Nasal Neoplasia	-60% are adenocarcnimoas or carcinomas -Commonly associated with epistaxis/nosebleeds in older dogs -Sneezing, nasal discharge, facial deformity might be present -Look for metastasis with thoracic radiographs -Metastasis is rare --can spread to regional lymph nodes and lungs -Also do nasal radiographs and CT -Endoscopy, rhinoscopy -Biopsy --flush, cup forceps, endoscopy
	Retropulsion and nasal disease	-Important to check ocular retropulsion -Nasal neoplasia can break out into the eye -If one side retropulses and the other does not, suspect that something is sitting behind the globe
	Dog Nasal Neoplasia Treatment	-Palliative treatment rater than curative -No real treatment, surgery alone is not a good option --3-6 month survival either way --no way to get adequate margins with surgery -Radiation therapy is effective -Most live 580 days --if a dog lasts to 1 year, it will probably last to 2 years
	Nasal Neoplasia in Cats	-Lymphosarcoma is the most common -Treat with radiation, with or without chemotherapy
	Fungal Rhinitis	-Cause for 12-34% of chronic rhinitis cases in dogs -Aspergillosis and penicillium species are common -Saprophytes in grass and soil -Immunosuppression in affected dogs? -Profuse unilateral or bilateral mucopurulent nasal discharge -Nose may be depigmented and ulcerated
	Fungal Rhinitis Diagnosis	-Culture is unreliable, 40% of dogs have aspergillus normally -Radiographs may show destruction of nasal turbinates --areas of lucency, air filled areas -Rhinoscopy may show fungal plaques --look like cauliflower with gravy -Serology: ELISA, agar gel immunodiffusion, counter immunoelectrophoresis
	Fungal Rhinitis Radiographs	-Bony detail is not normal, but does not look like cancer -Fungus eats away at the turbinates, leaves AIR lucency -Will also see on CT
	Fungal Rhinitis Treatment	-Clotrimazole: topical 1 hour infusion in propylene glycol formulation --propylene glycol formulation is key -Initial success rate is 70-75% -Some animals need more than one treatment -Topical enilconazole 2x daily via indwelling tubes for 10 days --89-90% effective -Oral medications are not effective --ketoconazole, intraconazole
	Feline cryptococcosis	-Cryptococcus neoformans -Thin-walled saprophytic yeast -Associated with pigeons -Transmission via inhalation, ingestion, skin inoculation -Sneezing, nasal discharge -Mass in nostril, swelling over the bridge of the nose -Can look like neoplasia -Pulmonary lesions will be present in 30% of affected cats -Diagnosis with cytology of nasal exudate, budding, or biopsy -Latex agglutination for capsular antigen -Fungal association on Sabaroud's agar -Treat with oral and IV drugs
	Dental Disease and Nasal Disease	-deep peridontal pockets can erode into nasal cavity and maxillary recess -Pulp exposure and apical abscess/loss of bone can cause extension of infection into the nasal cavity -Treat the underlying dental disease and close oro-nasal fistulae
	Choanal Disease	-Membranous destruction in young cats -Scarring secondary to vomiting in some animals -Trauma -Can be due to nasopharyngeal polyps in cats --come from middle ear, base is in the middle ear --can block the nasopharynx
	Pulling Nasopharyngeal Polyps	-Can pull out, but will usually leave something behind -Have to go into the middle ear (origin) and clear out --otherwise will re-grow
	Other Nasal Diseases	-Foreign bodies -Parasitic Rhinitis -Allergic rhinitis -Ciliary dyskinesia
	Brachycephalic Airway Disease	-Underdevelopment of the skull compared to the develpoment of the soft tissues of the pharynx and palate -Increased resistance to airflow -Everything is crammed into a shortened skull
	Primary abnormalities in Brachycephalic airway disease	1. Stenotic nares 2. Overlong soft palate 3. Hypoplastic trachea --NOT collapsing trachea, just small trachea
	R= (8 n l)/ pi r^4	-Resistance is inversely proprotional to the 4th power of the radius --all other values remain fairly constant -Resistance increases 16x if radius decreases -Resistance to airflow increases as length of tube increases --increases as radius decreases -Radius is critical!
	Nostril purpose	-Supposed to create turbulence -Allows recirculation of air for smelling purposes -If too narrow, animal cannot breathe
	Soft palate and turbulence	-Long soft palate increases turbulence
	Secondary abnormalities in Brachycephalic airway disease	-Everted mucosa of the lateral ventricles --"everted laryngeal saccules" -Laryngeal collapse -GI ulceration
	Anatomy of the Larynx	-Corniculate process -Laryngeal inlet -Cuneiform process -Aryepiglottic fold -Vocal folds -Vesticular fold -Epiglottis
	Frequency of concurrent disease in brachycephalic airway disease	-Everseion of lateral ventricle mucosa: 53% --everted saccules -Hypoplastic trachea: 34% -Moderate laryngeal collapse: 19% -Severe laryngeal collapse: 13% -Cardiac disease: 16% --often hard to hear with overlying airway disease -Diffuse gastric inflammation: 75% -Esophagitis: 36%
	Hypoplastic trachea	-Not the same as a collapsing trachea -Causes HUGE resistance to airflow -Can see on radiographs -Measure tracheal diameter vs. width of the thoracic inlet --in normal dogs, 20-22% --non-bulldog brachycephalics: 16-20% --normal bulldogs: 12-14% (MUCH smaller!!)
	How to measure for a hypoplastic trachea	1. Measure thoracic inlet 2. Measure trachea 3. Divide trachea measurement by thoracic inlet measurement
	Bulldog Tracheal Rings	-Smaller ring -C-shaped ring overlaps itself -Ring looks thicker -Sometimes the trachea can grow as the animal grows, sometimes it stays small with the animal
	Clinical Presentation of Hypoplastic trachea	-Inspiratory dyspnea -Dyspnea is worsened by weather, exercise, increased temperature --maybe also worsened with allergies -Increased muscular activity leads to cyanosis, hyperthermia, and collapse --breathing against stenosis is WORK --generates heat and leads to hyperthermia -Gagging, retching --can lead to aspiration pneumonia
	Emergency presentation of Hypoplastic trachea	-Severe dyspnea, hyperthermia, exhaustion, collapse -Possible aspiration -Some animals improve with cool IV fluids, sedation, O2, corticosteroids --cool CORE temperature -Intubation may or may not help -tracheostomy
	Treatment for Emergency hypoplastic trachea	-Cool IV fluids to cool core temperature -Sedation -Low dose soluble corticosteroids -Supplemental O2 -Tracheostomy tube can be placed with animal already intubated
	Evaluation of a dog with hypoplastic trachea	-Physical exam -Thoracic radiographs -Cardiac evaluation --Need to listen to the heart! --scratch ear, put finger in the ear of the dog --turn on tap water for a cat -Evaluate pharynx/larynx under light anesthesia --have to look to see how bad it is -MUST do surgical correction at time of evaluation!
	Stenotic nares	-Cartilages of the external nares are shortened and thickened --obliterate nasal vestibule -Remove part of the dorsal lateral nasal cartilage --cut out wedge and suture 2 edges together --use resorbable suture! do not want to have to go back and remove! -Control hemorrhage, will bleed a lot --control with pressure and sutures
	Elongated Soft Palate	-Soft palate is so long it closes off airway during normal inhalation -Soft palate also closes off back of the nasopharynx during swallowing --when repairing do not want to shorten too much, will decrease seal during swallowing
	Surgical correction of Elongated Soft Palate	-Resect soft palate to the level of the caudal border of the tonsil --can use CO2 laser --manual resection with over-sew of edges to prevent hemorrhage -Use simple continuous suture, cannot bleed --seals 2 surfaces together
	Complications while correcting Elongated Soft Palate	-Hemorrhage -Swelling -Respiratory obstruction -Gag/retch/vomit reflex -Aspiration pneumonia
	Elongated Soft Palate correction Prognosis	-Better for dogs diagnosed and treated early -Better if stenotic nares are treated at the same time -Worse if laryngeal abnormalities are present --indicates more severe airway disease --secondary disease
	Everted laryngeal Saccules	-Have to cut out of the way
	Extubating animal with airway disease	-Leave animal intubated for as long as possible -Look at chest wall AND listen for airway sounds before extubating
	Laryngeal Collapse	-Very bad news -Secondary change associated with chronic upper airway obstruction and increased respiratory effort -Cuneiform and corniculate processes of arytenoid cartilages are drawn into the glottic opening --larynx is folded in on itself -Usually associated with everted saccules and severe dyspnea -Permanent tracheostomy is the only option for treatment!
	Brachycephalic Sleep Apnea	-Apnea occurs during REM sleep -Associated with decreased pharyngeal dilator activity -Apnea is terminated by massive bursts of muscle activity -Chronic over-activity is associated with muscle fibrosis -Whole pharynx collapses in on itself --with breathing, pharyngeal muscles can become damaged
	English Bulldong and Sleep Apnea	-Animal model of sleep-disordered breathing -Hypersomnolence -Snoring -Apneic events -Sternohyoid muscle can have focal necrosis due to increased effort in breathing --muscle scarring, muscle works poorly --condition develops over time
	GI ulceration in brachycephalic dogs	-GI ulceration and lesions associated with brachycephalic airway disease -Ulcerations in esophagus or stomach -Esophageal ulceration makes sense -Gastric ulceration makes no sense -Treat with antacids
	Ear Disease	-Ear disease is SKIN disease --ear is lined by nothing but SKIN
	Cartilages of the outer ear	-Pinna -Vertical canal/external auditory meatus --surrounded by auricular cartilage -Horizontal canal --surrounded by annular cartilage --facial nerve runs ventral to annular cartilage near parotid gland
	Diagnostic Investigation of Ear Disease	-Determine the primary cause --skin disease in other locations? -Clean the vertical and horizontal ear canals -Assess tympanic membrane -Take samples for cytology, culture, sensitivity -Imaging can be helpful -Can be hard to find an underlying cause
	Primary causes of Otitis	-Parasites -Foreign bodies -Yeast -Allergic skin disease --inhaled or food allergy -Disorders of keratinization -Generally NOT due to bacteria
	Cerumen	-Black, waxy discharge -Occurs in response to almost any sort of infection
	Otodectes	-Ear mites -Can be primary cause of ear disease
	Yeast	-Can be a primary cause of ear disease -Treatable
	Seborrhorea	-Abnormal growth of keratinized stuff -Can lead to secondary bacterial infections
	Yellow discharge from the ear	-Hypothyroidism
	Bilaterally symmetrical alopecia	-Probably an ENDOCRINE disease
	Ear neoplasia	1. What is it? 2. Where is it? 3. What if I do something? 4. What if I do nothing?
	Bacteria in ear infections	-Bacteria is usually secondary to other cause
	Aural Hematoma	-Usually occur on medial aspect of the ear -Between skin and cartilage of the ear -Have to drain, leaves dead space --put in drain, skin cannot adhere to cartilage and problem is never solved -treat by draining, then putting sutures all the way through the ear --tie sutures loosely to allow for swelling --put sutures in plane of blood supply, do not want to cut off blood supply
	Assessing Vertical and Horizontal Ear Canals	-Need general anesthesia, hard to get animal to hold still -Sterile saline flush and suction --do not use chlorhexidine, can cause deafness --use something that will break up the wax -Take samples for cytology, culture and sensitivity -Check patency of the horizontal canal -Check for presence/absence of tympanic membrane -Look for masses
	Ear neoplasia	-Can cause unilateral otitis -Always biopsy!
	Aural polyp	-Benign lesion -Originates in the middle ear -Can grow outwards to ear canals or inwards to nasopharynx
	Indications for Aural Surgery	-Failure of medical therapy -Relapses after initial successful medical therapy -Hyperplastic/obstructive changes are present -Neoplasia -Para-aural abscess
	Lateral Ear Canal Resection	-Open up the ear canal -Shortens the length of the ear canal -Promotes better drainage of the horizontal canal --allows drainage -Changes the micro-climate of the remaining ear canal -Allows access for medication -MUST have patent horizontal canal for surgery to be successful --if closed, will not have drainage and surgery is too late -Put in loose sutures to accommodate swelling -Will fail if underlying skin disease is not corrected
	Failed Lateral Ear Canal Resection	-Poor surgical technique (rare cause of failure) -Surgery performed too late in the course of disease --irreversible changes of vertical canal wall --inadequate drainage from horizontal canal, horizontal canal is occluded -Underlying otitis media -Ongoing and unresolved skin disease
	Otitis Media Diagnostic Dilemma	-Diagnostic gold standard is histopathology -Clinical signs are similar to otitis externa -Need to evaluate tympanic membrane --otoscopy --probing --impedance audiometry -Radiographs are not always reliable
	Clinical signs of Otitis Media and Otitis Externa	-Head tilt -Scratching -Shaking the head-Discharge
	Bullae on Radiographs	-ON lateral projection are superimposed -Position animal with mouth towards the X-ray beam -Cat middle ear has 2 compartments, need to clean both -Upper respiratory infections can close off eustacian tube --middle ear will not be able t drain
	Otitis Media Treatment Options	-Flush under general anesthesia --use antibiotics based on culture and sensitivity results --will work 75% of the time -Lateral wall resection and ventral bulla osteotomy --75% success rate --failures had related skin disease that was not resolved -Total ear canal ablation or bulla osteotomy
	Ear Surgery Hazards	-Very delicate structures in the area --carotid artery --glossopharyngeal nerve -Need to drill in the right spot!
	Total Ear Canal Ablation	-Salvage procedure, very challenging -Not often done in dogs, more often in cats -Indicated when there is irreversible hyperplasia of the horizontal canal --end stage otitis -Trauma to the ear, including avulsion can be indication -Neoplasia -Para-aural abscess -ALWAYS combined with a bulla drainage procedure, always open bullae
	Structures in the area of the Ear	-Facial nerve -Parotid gland -Mandibular gland -Great auricular artery -Maxillary artery -Superficial temporal artery
	Issues with Ear Surgery	-Chronic inflammation, everything bleeds! -Facial nerve is close to surgical site -Many important vessels are close to the surgical site
	Complications of Ear Surgery	1. Hemorrhage 2. Facial nerve paralysis or paresis --facial nerve is stuck onto the ear canal, have to pull it off to preserve it 3. Wound breakdown and infection 4. Fistula formation
	Ear Canal Neoplasia	-A few kinds are present in dogs --Remove pinna and ear canal ablation to treat -in cats usually ceruminous gland adenocarcinomas --usually very bad, metastasize to lymph nodes quickly
	Aural Neoplasia	-Check for metastasis --lymph nodes and thoracic radiographs -Check extent of local disease --radiographs, CAT scan -Total Ear Canal Ablation
	Cat middle ear	-Has 2 compartments
	Inflammatory polyps	-Associated with signs of upper respiratory tract -Associated with ear disease in cats -Originate from the middle ear --start in middle ear, go up into the pinna, go down into the eustacean tube and into nasopharynx -Can grow either out into ear canal or into nasopharynx or both -Look in both ears!
	Inflammatory polyp treatment	-Steroids -Often re-occur with out bullar osteotomy --recur due to small amount of polyp tissue in the middle ear
	Esophagus	-Has 4 main areas of narrowing --origin, thoracic inlet, heart base, caudal esophageal sphincter -Innervated via special visceral and efferent fibers --supplied by branches of the vagus and sympathetic fibers -Blood supply comes from cervical esophagus --thyroid arteries and esophageal branches of the carotids --thoracic esophagus is supplied by bronchoesophageal arteries --esophageal branches of the aorta and left gastric artery
	Regurgitation vs. Vomiting	-Regurgitation: look for issue in the esophagus --food will be undigested -Vomiting: look for metabolic disease or GI obstruction
	Cricopharyngeal Achalasia	-Cricopharyngeus muscle forms sphincter around the cranial esophagus -Muscle Normally relaxes in association with pharyngeal contraction --relaxation allows food bolus to pass during swallowing -Abnormal function results in food staying in the pharynx --bolus of food cannot get past cricoid cartilage and cricopharyngeus muscle --stimulates forceful pharyngeal movements and regurgitation -Uncommon in dogs -Congenital abnormality in cocker and springer spaniels -DDx: pharyngeal foreign bodies, mass lesions, myositis, paralysis
	Cricopharyngeal Achalasia Diagnosis	-Usually identified in puppies at or post weaning -Confirmed by barium fluoroscopy in awake animal -Tx: cricopharyngeus myotomy to allow passage of food -Prognosis is good if diagnosis is correct --if cut animal unnecessarily, allows aspiration
	Esophageal Foreign Bodies	-Points of contact between esophageal mucosa and foreign body can result in necrosis -Spasm of esophageal muscles may worsen changes -Necrosis can extend throughout the entire esophageal wall --may result in perforation and leakage of esophageal lumen contents into the mediastinum and pleura, resulting in sepsis
	Removal of Esophageal Foreign Bodies	-Remove with scope! Need good light source -Blow air into the esophagus, insufflate around the foreign body -May be able to push FB down into the stomach if made of right material and right smoothness --do not want to create more damage!
	Endoscopy for Esophageal Foreign Bodies	-Allows diagnosis, treatment, and evaluation
	Surgery of the Cervical Esophagus	-Take ventral mid-line approach -When suturing the GI, suture the submucosa --has collagen, will hold better -ALWAYS use simple interrupted appositional suture pattern
	Surgery of the Esophagus near heart base	-Have some big vessels to be concerned about! -Azygous vein on the right, aorta on the left --go in on the right! lateral flank between 5th and 6th rib
	Surgery of the Caudal Esophagus	-Go in between 8th and 9th rib -Esophageal perforation in the caudal thorax is bad news!
	Principles of Esophageal Surgery	-Anatomy and approach are important -Submucosa is the holding layer -Single layer closure vs. 2 layer closure -If there is a lack of omentum use substitutes -Nutrition is important
	Esophageal Strictures	-Foreign bodies -Trauma -Esophageal surgery can result in fibrosis and stricture -Results in reflux esophagitis, reflux of gastric contents -Deeper ulceration results in greater chance of stricture
	Reflux esophagitis	-Most common cause is esophageal stricture -Usually secondary peristalsis pushes ingesta back into the stomach -Alkali and bile are more damaging than acid -Under anesthesia, caudal esophageal sphincter relaxes --digesta can re-enter the caudal esophagus --DO NOT give animal food 6-12 hours before surgery! -Mucosal erosion leads to inflammatory response which leads to fibrosis an scarring
	Anesthesia and reflux esophagitis	-Anesthesia relaxes the caudal esophageal sphincter, decreased tone -Swallowing and secondary peristalsis do not occur under anesthesia -Gastric contents can reflux -Alkali and bile are more damaging than stomach acid
	Clinical Signs of Esophageal Stricture	-Increasing difficult with solid food -Inability to retain anything but liquids -Weight loss in long-term cases -Aspiration pneumonia -Depressed, febrile, excessive drooling -Barium contrast fluoroscopy and esophagoscopy show stricture
	Treatment for Esophageal Stricture	-Prevention is better than treatment, prevent! -Need surgical treatment -Fasting for 12 hours before anesthesia -Can have balloon dilation for stricture, put balloon in and expand --inflates area uniformly --will not rupture esophagus very often, although rupture is a risk
	Esophageal Tumors as cause of Esophageal Stricture	-Rare -More often metastatic than primary neoplasia -Leiomyoma, squamous cell carcinoma, fibrosarcomas are all common -Can be due to spirocerca lupi infection and granuloma formation --associated with osteosarcoma and fibrosarcoma of esophagus -Usually very large by the time diagnosis occurs -Need to have big margins with removal, hard to get full margins in tight area
	Megaesophagus	-Most often due to failed regression of right aortic arch -Esophagus passes through space between pulmonary artery, aorta, and ligamentum arteriosum --normally not trapped via ligamentum, has space to expand -Esophagus and trachea are trapped
	Megaesophagus Treatment	-remove ductus arteriosus/ligamentum arteriosum -ALWAYS assume there is blood flow in ligamentum, LIGATE!
	Embryology of Megaesophagus	-Dorsal and ventral paired aortas are connected by pairs of aortic arches -Dorsal aortas fuse from descending aorta -Ventral aortas form arterial outflow tract from base of the aorta to carotid arteries -Arches I and II involute -Arch III becomes origin of internal carotids -Arch IV (on left) connects fused ventral aortas to descending aorta, should persist -Arch IV (on right) forms Right subclavian artery -Arch V involutes -Arch VI forms pulmonary arteries on right --ductus/ligamentum arteriosum on left -Persistent RIGHT aortic arch results in megaesophagus
	Radiographic Tracheal Deviation in Persistent Right Aortic Arch Study	-52/55 dogs had persistent right aortic arch -44% had co-existing compressive arterial anomalies -31% had retroesophageal subclavian arteries -11% had double aortic arches with atretic left arch -LEFT deviation of the trachea was seen in 100% of dogs with right aortic arches in DV or VD --trachea hooks over to the left
	Nasal Disease Signalment	-Can help form a list of differential diagnoses -Age: --young dogs get congenital disease --young cats get viral diseases --Old dogs get dental related diseases and cancer
	History and nasal disease	-Age -Travel History -Environment and exposure -Progression -Response to treatment -Medical history (anesthesia, prior procedures, prior diseases)
	Nasal Discharge	-Excessive production of mucus and serous production from nasal mucosa OR decreased drainage -Nose drains backwards, stuff is pushed back into nasopharynx and swallowed -Blockage means stuff comes forwards instead of going down -Discharge varies with type and duration of underlying disease --gives indication fort source of disease
	Character of Nasal Discharge	-Serous (viral infections, allergies) -Mucoid -Sanguineous (blood component) -Purulent (thick, associated with bacterial infection) -Mucopurulent (infectious diseases) -Epistaxis (Result of local OR systemic diseases)
	Location of nasal Discharge	-Unilateral --dental related --neoplasia -Bilateral --inflammatory diseases --advanced fungal infection --advanced cancer -Interpret in light of clinical signs!
	Nasal Discharge Onset	-Peracute: foreign body inhalation -Acute: viral respiratory disease in cats --early chronic diseases -Chronic
	Important things to know about nasal discharge	-Character -Location -Onset
	Sneeze	-Superficial reflex -Leads to forceful expulsion of air from the nose and mouth -Contraction of muscles of expiration -Nose is trying to expel irritants -Irritation of nasal mucosa stimulates nerve endings that act on receptors initiating the sneeze reflex
	Stertor	-"To Snore" -Snore-like sound on inspiration -Due to "things in the nasopharynx" -Produced by vibration of nasal tissue or by movement of air through a partial obstruction of nasal passage by fluid or tissue -Often indicates conditions affecting the nasal passages, choanae, or nasopharynx
	Stridor	-Harsh, creaking sound in airway -High-pitched respiratory sound -Usually heard on inspiration -Older lab retrievers with laryngeal paralysis -Often indicates condition affecting larynx or cervical trachea
	Reverse Sneeze	-Rapid, noisy, paroxysmal inspiratory effort -Usually occurs with a closed mouth -May indicate caudal nasopharyngeal irritation -Often little pathogenic significance if any
	Physical Exam of the Nasal Cavity	-Oral exam, dentition and palate -Detection of airflow (cotton ball or glass slide) -Facial symmetry or asymmetry -Palpation of regional lymph nodes -Retropulsion of globes, should feel symmetrical and should move back into the orbit -Nasal planum changes (depigmentation, plaques, etc.) -Fundic examination
	Important info for Nasal Disease Differential Diagnoses	-Signalment, History, and physical exam are crucial in establishing a list of differential diagnoses
	Nasal Disease case work-up	-CBC, chemistry screen, urinalysis -Hemostatic tests -Blood pressure -Chest radiographs --rule out pneumonia -Infectious disease screening -Aspiration of local lymph nodes -cytology of nasal discharge (not super helpful usually) -Imaging -Rhinoscopy
	Nasal CT	-Useful to distinguish neoplasia and inflammatory/infectious disease -Assessment of regional lymph nods -Assessment of cribriform plate -Can do radiation planning -CT and rhinoscopy are complementary!
	Nasal Endoscopes	-Rigid endoscope -Flexible endoscope -Can do a retroflex rhinoscopy --limited view, just caudal portion of choanae and nasopharynx -Use to look at muscosa and assess health of mucosa -Can guide biopsy -CT and rhinoscopy are complementary!
	Nasal causes of Nasal Disease	-Congenital -Inflammatory -Infectious -Neoplasia -Foreign body -Oral disease Dog: lymphoplastic rhinitis, neoplasia, fungal rhinitis Cat: neoplasia and chronic rhinitis
	Systemic causes of Nasal Disease	-Really only cause epistxis -Hemostatic disorders -Vasculitis -Hyperviscosity -Hypertension
	Infectious Diseases of the Nasal Cavity Cats	-Feline herpesvirus-1(Corneal ulcers) -Feline calicivirus (lingual ulcerations) -Chlamydophila felia (more conjunctival disease) -Mycoplasma -Bordetella bronchiseptica
	Treatment of Infectious Viral Rhinitis in Cats	-Supportive care --nutritional support, can't smell and won't want to eat --nebulization and humidification --Antimicrobials (doxycycline) --L-lysine, a-interferon --Nasal flushing, clear airways
	Bacterial Rhinitis	-Does not really cause nasal discharge -Can occur secondary to any other disease of the nasal cavity --fungal, neoplasia -Cultures are usually polymicrobial -FIND UNDERLYING CAUSE!
	Nasal Parasites	-not very common 1. Pneumonyssoides caninum --small mite, can see crawling on nasal planum or on endoscope --treat with selamectin, milbemycin, ivermectin 2. Eucoleus boehmi: --nematode parasite --diagnose with fecal float or nasal flush --treat with fenbendazole or ivermectin 3. Cuterebra: --bot fly larvae --diagnose with endoscopic visualization --extract! or give ivermectin
	Nasal Cryptococcus	-Cryptococcus neoformans, fungus! -Transmitted from bird poop -Causes localized nasal disease or disseminated CNS disease -Most common in cat, rare in dog -Mucopurulent nasal discharge --starts unilateral, progresses to bilateral --will see obstructive signs -Local lymphadenopathy -Retinal lesions -Facial deformities (roman nose) -Concurrent mucopurulent conjunctivitis
	Nasal Cryptococcus Diagnosis	-Antigen test, simple blood test -Cytology -histopathology -CT/rhinoscopy
	Nasal cryptococcus Treatment	-Treat with Fluconazole anti-fungal --can penetrate into CNS -Infection can go through cribriform plate and into CNS! -Prognosis decreases if there is CNS involvement
	Saprophytic Fungal Rhinitis	-Aspergillosis -Most common in Dogs -Dolcecephalic dogs are at greater risk
	Saprophytic Fungal Rhinitis Clinical Signs	-Nasal depigmentation -Mucopurulent discharge --may have blood component --may just be epistaxis! -Sneezing -Unilateral discharge progressing to bilateral discharge -Facial pain, organism is destroying bone -Fever, weight loss, anorexia, lethargy, animal is SICK with advanced disease
	Saprophytic Fungal Rhinitis Diagnosis	-Endoscopic visualization of fungal plaques -CT gives high suspicion ("empty" nasal cavity where turbinates should be) -Serology is available for Aspergillus (poor sensitivity) -Culture (takes a LONG time! not very specific) -Cytology or histopathology for confirmation -Hard to see bony changes on X-ray, need anesthesia and don't give great image
	Saprophytic Fungal Rhinitis treatment	-Treat with infusion of anti-fungal medication -Clotrimazole or enilconazole infusion -Has high success rate, 70% resolution -May take multiple treatments --treatment involves general anesthesia --only way to know re-treatment is needed is CT -Systemic therapy with azoles is less effective --only use if cribriform plate is not intact on CT, do not want azole to soak the brain -Debride the fungal plaques -Use foley catheter and balloons to obstruct the nasopharynx, keep azole within the nasal cavity
	Neoplasia of the Upper respiratory tract	-Nasal neoplasia is typically malignant, locally aggressive -Canine: ADENOCARCINOMA, squamous cell carcinoma, sarcomas, lymphosarcoma -Feline: LYMPHOSARCOMA, squamous cell carcinoma, adenocarcinoma, saromcas -Older, large-breed dogs are most common -Most affected animals will have secondary bacterial infections also
	Clinical Signs of Nasal Neopastic Disease	-Chronic nasal discharge -Obstructive signs --stertor, trouble breathing -Unilateral, often progressing to bilateral -Sneezing -Facial deformity -Exophthalmia -Reduced nasal airflow -Nasal planum ulceration with feline squamous cell carcinoma -Local lymphadenopathy
	Diagnosing Nasal neoplasia	-CT -Rhinoscopy -Do BOTH CT and rhinoscopy! Can miss things with just rhinoscopy -Cytology or histopathology
	Nasal neoplasia Treatment	-Radiation therapy -Rhinotomy with radiation -Chemotherapy -COX-inhibitor therapy -Antimicrobials for secondary infections
	Nasal neoplasia Prognosis	-Dogs: 7 months with radiation therapy -Cats: 1 year or more with radiation therapy or chemotherapy
	Nasopharyngeal Polyps	-Benign pedunculated masses -Can come from auditory tube OR middle ear -Fibrovascular and inflammatory tissue -Occur in young cats, 1/3 of all feline nasopharyngeal disease is polyps!
	Clinical signs of Nasopharyngeal Polyps	-Serous to mucopurulent nasal discharge -Stertor -Sneezing -Diagnose by checking palate and ears -Can also diagnose with imaging
	Nasopharyngeal Polyp Treatment	-Traction avulsion, rip out --recurrence is possible, 33% -If in middle ear, should do ventral bulla osteotomy --more frequent recurrent if not removed surgically -Temorary horner's syndrome is common --miosis, ptosis, enophthalmos
	Canine Lymphoplasmacytic Rhinitis	Idiopathic, poorly understood -Can be from infection, aeroallergens, inhaled irritants -Young to middle aged dogs -Colichocephalic dogs most commonly, large breeds and dachshunds -Chronic and progressive
	Clinical Signs of Canine Lymphoplasmacytic Rhinitis	-Usually bilateral nasal discharge -Most commonly mucoid to mucopurulent discharge -Epistaxis may be seen -Diagnose with CT and rhinoscopy or histopathology -Hard to exclude all other causes
	Canine Lymphoplasmacytic Rhinitis Treatment	-Not standardized -Antibiotics -NSAIDs -Inhaled/systemic/topical steroids -Prognosis is difficult, disease is chronic and progressive
	Allergic Rhinitis	-Uncommon in dogs -Diagnosis of exclusion -Seasonal serous nasal discharge -Usually responds to corticosteroids, anti-histamines, or immune-modulation
	Nasal Foreign Bodies	-Most common cause of peracute sneezing and discharge in dogs -Usually due to plants, grass awns, strings, bones -Serous discharge that can progress to mucopurulent
	Epistaxis	-Destructive local disease (most common) --neoplasia, trauma, rhinitis -Systemic disease --thrombocytopenia --thormbopathia --coagulopathy --vasculitis
	Persistent Deciduous Tooth	-Deciduous tooth that has not exfoliated -Should exfoliate by 5 months of age -"Retained" tooth-Problematic for maxillary and mandibular canine teeth --causes malocclusion -Compete for space with erupting permanent teeth -Can cause crowding, entrapment of food -Can cause permanent canine tooth to erupt in the wrong position --results in pain --Can result in oronasal fistula -Rule for teeth: --"there should never be a tooth of the same kind in the same place at the same time"
	Treatment for Persistent Deciduous Tooth	-Extraction
	Unerupted Teeth	-embedded, no reason for tooth to be unerupted -Impacted: there is some reason tooth has not erupted --another tooth sitting on top of tooth -Can result in dentigerous cysts if left untreated -Mostly in mandible -1st premolars
	Dentigerous Cyst	-Result of impacted unerupted teeth -Folicular cells develop cysts around crown of unerupted teeth -Can become so large that bone surrounding the teeth gets resorbed --Adjacent teeth are displaced -Teeth within the cyst undergo changes, are absorbed or infected -Cyst lining can undergo neoplasia, should be removed completely -Will have radiolucent area around tooth in cyst
	Dentigerous Cyst Treatment	-Open cyst -Extract tooth -Remove entire cyst lining
	Malocclusion	-Almost no canine in the wild has malocclusion --will not survive, genes will not be passed on -Humans breed malocclusion in dogs --boxers, pugs, shelties, collies
	Class 1 malocclusion Dental malocclusion	-Neutroclusion -Teeth do not match up perfectly -Affects one or more teeth -Normal upper/lower jaw relationship, teeth are just out of line -Will not correct if there are no issues with pain or eating
	Class 2 Malocclusion	-Lower jaw is shorter than the upper jaw -Overbite -mandibular distoclusion -Symmetric malocclusion -Common in collies, german shepherds, other long-nosed dogs -Lower/mandibulat canine occludes into the hard palate --can result in oronasal fistula
	Class 3 malocclusion	-Lower jaw is longer than the upper jaw -Underbite -Mandibular mesioclusion -Symmetric malocclusion -Common in boxers -Do not treat, animal is bred to be this way
	Asymmetric malocclusion	-One side of the face is longer than the other side of the face -Mouth is open, animal cannot completely close the mouth --air constantly moves into the mouth, causes irritation of the gingiva and dry mouth --animal will drool more
	Number of permanent teeth in a dog	-42 teeth -All dogs develop the same number of teeth, no matter what facial conformation -If face is smushed, teeth become rotated in order to fit into the jaw --Crowding leads to places for food to get stuck between the teeth
	Persian cat malocclusion	-Malocclusion due to breeding -Face becomes shorter and shorter -Severe gingival inflammation -Can treat with selective extraction
	Periodontal Disease	-Most common infectious disease in all mammals -Caused by plaque bacteria -Loss of attachment can lead to mobile tooth and eventual loss of tooth -Gingivitis -Periodontitis -Can have a systemic effect! Associated with many other diseases --diabetes, kidney disease, liver disease, changes in myocardium
	Gingivitis	-Inflammation of the gingiva -Can treat by removing the plaque layer --reverses gingivitis
	Periodontitis	-Inflammation has gone from the gingiva into deeper tissues --progressive peridontitis -inflammation of the gingiva, alveolar bone, periodontal ligament, cementum -Results in bone loss -Tooth becomes mobile and eventually falls out
	Periodontal disease treatment	-Professional dental cleaning -Periodontal therapy -Periodontal surgery -Home oral hygiene -removing calculus only does not reduce risk for periodontal disease
	Gingival Hyperplasia	-Histological term, NOT swelling in the mouth -Need to sample tissue -Common in brachycephalic dogs -Caused by inflammation, anti-convulsants, cyclosporines, Ca channel blockers -Treat by gingivectomy or gingivoplasty
	Gingivectomy	-Remove portion of the gingiva that is enlarged
	Gingivoplasty	-Shaping the cut gingiva so it looks physiologic
	Stomatitis	-Inflammation of oral mucosa other than gingiva --buccal mucosa, other mucosas, etc. -Contact mucosal ulceration, erosion of mucosa that is touching a tooth covered with plaque -Caudal stomatitis in cats, inflammation far back in the mouth --inflammation can come forwards and affect the gingiva
	Contact mucosal ulceration	-Inflammation of mucosa that is facing teeth -Kissing lesion -Mucosa is "kissing" the surface of the tooth that is covered in plaque -Mucosa covering the plaque loaded surface is reacting -Ulcer develops
	Treatment for Stomatitis	-Professional dental cleaning -Selective extractions of teeth affected by other diseases -Full mouth extractions -medications --antimicrobial, anti-inflammatory, immunosuppressive, antiviral -Burning away inflamed mucosal tissue --turns heavily vascularized tissue into scar tissue, fewer blood vessels, less chance for inflamamtion to occur
	Palatoglossal Fold and Caudal Stomatitis	-Fold is the caudal border of caudal stomatitis in cats -Stomatitis stays within the oral cavity, does not involve the pharynx
	Eosinophilic granuloma	-Seen in both cats and dogs --cats: upper lip, hard palate, tongue --dogs: soft palate and tongue -Biopsy for confirmation of the disease -treat medically with corticosteroids --rarely treat surgically -Easily confused with squamous cell carcinoma, biopsy is essential! -If not treated, can erode away until there is a hard palate defect
	Tooth Resorption	-Very common in cats, can also occur in dogs -More prevalent that peridontal disease in cats -Unknown cause, excess dietary vitamin D? -Inflammatory resorption vs. replacement resorption -Associated with tooth extrusion and alveolar bone expansion -Leaves root remnants in the jaws
	Tooth Resorption Treatment	-Extraction -Crown amputation if root has already fused with bone --intentional retention of resorbing root tissue -Endodontic therapy -Restoration in selected cases
	Caries Conditions	1. Cariogenic bacteria, need "sour" environment --more acidic pH 2. Cariogenic diet: high refined sugar diet 3. Cariogenic tooth surfaces: pits where bacteria can hide
	Caries	-Demineralization of dental hard substance -Rare in dogs (3-5%), rare in cats -Dogs and cats do not normally have predisposing environment, diet or tooth surfaces for Caries -Humans give dog human food, certain teeth can get caries lesions --1st and 2nd molars in upper jaw -Treat with root canal therapy, restoration, or extraction of tooth
	Dental Attrition	-Tooth wear from teeth contacting each other -Teeth are not meant to touch each other -Occurs due to malocclusion
	Dental Abrasion	-Tooth wear caused by contact of tooth with non-dental material --tennis ball, stick, hard chew toy, etc. -Skin and hair
	Treatment for Tooth wear	-Extraction -Root canal therapy -Replacement -Tooth crown -Remove underlying cause for wear
	Tooth Fracture	-Uncomplicated vs. complicated -Crown fracture -Root Fracture -Dogs usually due to external trauma -Cats usually due to external trauma and tooth resorption -treat by extraction or root canal therapy
	Uncomplicated tooth fracture	-Tooth Fracture without pulp exposure
	Complicated tooth fracture	-Tooth Fracture with pulp exposure
	Things that are too hard for dogs to chew	-Antlers -Cow hooves -Ice cubes -Real bones
	Types of Tooth displacement INjury	-Luxation: tooth displaces but is still in alveolus -Avulsion: tooth is out of the alveolar socket --need to put tooth in MILK to save, only viable 3-6 hours -Usually tooth is extracted or kept out of the alveolus
	Intrusive tooth luxation	-Tooth is driven into the nasal cavity -Causes unilateral nasal discharge and epistaxis -Can look like neoplastic disease -Clearly seen on radiographs
	Endodontic and periapical disease	-Usually occurs due to fracture of a tooth -Disease spreads into the pulp and into periapical tissues --causes tooth root abscess, granuloma, or cysts -Treat by extracting, pulp therapy, root canal therapy, etc.
	Endodontic disease on radiographs	-Widened pulp cavity -Structural defects in the tooth -Lucency around apical roots of teeth
	Osteomyelitis and teeth	-Infection of the jaw due to tooth fracture involves remaining bone and bone marrow -Affects dogs more than cats -VERY painful condition -Extension of local infection or inflamamtion into deeper areas of bone --bone inflammation and necrosis -Debride affected tissues! If left alone, will cause more erosion of the bone
	Jaw Fractures	-Mandibular fractures: syphysis, body, ramus --dog: body --cat: symphysis --mandibular ramus fractures can also happen -Maxillary fractures: involve bones of the upper jaw and face, zygomatic arch -Need to know if teeth are within the jaw fracture line or not
	Mandibular ramus Fractures	-Typically pretty stable fracture -LOTS of masticatory muscles in that area hold fracture together -May not see any malocclusion
	Treatment for jaw Fractures	-Start with non-invasive techniques --do not have to reflect mucosa to access jaw --use teeth as anchor points to stabilize and fix fracture -Least invasive is tape muzzling (cheap, custom made, convenient) --good for immature animals, have huge healing capacity --can be used in addition to other techniques -Inter-arch bridging, bonding upper and lower teeth -Cerclage wiring to keep things together -interdental wiring and resin splinting (always used together) -Intraosseus wiring (quite invasive, need to drill holes into the bone) -Miniplating -USE NON-INVASIVE OVER INVASIVE!! -Debride and flush lesion before closure to reduce infection
	Other head Trauma	-Animal bites -Lip avulsion --cats: lower lip, usually young cats --dogs: upper lip, usually small dogs or puppies picked up at the snout and shaken -Gun shot wounds --can be very projectile, teeth become projectiles -Electric cord injuries --can involve lip injury, oral mucosa, hard palate, tongue, lots of damage -Treat depending on location and type --important to reduce dead space! --stop bleeding, stabilize the patient --do not reconstruct until swelling is resolved, wait for tissues to declare themselves
	TMJ Luxation	-More common in cats, less common in dogs -Unilateral rostro-dorsal luxation of the condyle --rarely luxates caudally due to retro-articular process -Lower jaw shifts towards the opposite side -Mouth cannot be fully closed due to contact between maxillary and manibular teeth -Can see on radiograph, condyle is lightly moved forward from the joint
	TMJ Luxation Treatment	-Manual reduction with wooden dowel/pencil fulcrum -Put fulcrum between maxillary and mandibular carnassial teeth on side where luxation has occurred --rotate pencil to put condyle forward and then back into the mandibular fossa
	Open-mouth Jaw Locking	-Locking of the coronoid process of mandible ventrolateral to the zygomatic arch --coronoid process is "outside" of zygomatic arch -Also related to TJM, usually has TMJ dysplasia --soft-tissue related, something wrong with joint capsule, loose joint --hard-tissue related, incorrect shape of the bones or articular surfaces -Typically in persian cats, bassett hounds, retrievers -Usually occurs when animal opens mouth very wide -Will see no contact between maxillary and mandibular teeth -Often bilateral issue -Slight shift of lower jaw TOWARDS the side where locking has occurred -Can see contact between coronoid process and zygomatic arch on radiographs -Animal is unable to close mouth on own, cannot correct -Animal will be drooling
	Open-Mouth jaw Locking Treatment	-Manual reduction under sedation -Open mouth further, then slightly rock lower jaw to midline and try to close -Hopefully "unlocks" coronoid process from the zygomatic arch -Partial zygomectomy or coronoidectomy can also be done --trim the coronoid process
	True TMJ Ankylosis	-Intracapsular ankylosis -Fusion of condylar process of mandible with mandibular fossa or retroarticular process of temporal bone -Small amount of trauma can cause overwhelming healing response and calus formation -
	False TMJ ankylosis	-Extracapsular ankylosis -Fusion in other areas, zygoma with the coronoid process and fused caluses
	TMJ Ankylosis in General	-Particularly common in young animals, cats more than dogs -Progressive inability to open the mouth -Need to be aggressive in bone removal -Bone is usually "young" and not lamellated -Use rongeur to remove little bits of bone -Once space is created between cut bony edges, suture muscle tissue over the bony edges to prevent re-fusion of the bone -Follow with high doses of cortocosteroids, prevents connective tissue formation -Prognosis is guarded to far -Will not see TMJ space on radiographs
	Masticatory Myositis	-Autoimmune disease -Body produces auto-antibodies that target myosin in masticatory muscles -Affects temporal, masseter, and medial and lateral pterygoid muscles -Does NOT affect digastricus muscle -Only reported in dogs -Can occur in dogs of any age, usually affects larger breed dogs -Diagnose via antibody titer for 2M-fiber or immunohistochemical staning of biopsy
	Masticatory Myositis Pathogenesis	-Auto-immune Antibody attaches to myosin in muscle fibers -Forms immune complex, immune complex attracts inflammatory cells -Will have muscle swelling due to inflammatory cells in acute phase -Inflammatory cells try to fight the immune complexes, causes bursting of neutrophils and release of toxic substances into the muscle tissue -Results in necrosis, pain, atrophy
	Masticatory Myositis Treatment	-Immunosuppressive corticosteroid therapy -Taper to lowest effective dose over 8-12 months
	Clinical signs of Masticatory Myositis	-asymmetrical of temporal muscle -Swelling of the masseter muscle -Inability to open the mouth -Painful on palpation -Enlarged lymph nodes -Contrast enhancement of muscles on CT -Digastricus muscle is NOT affected
	Craniomandibular osteopathy	-Excessive new bone formation (woven bone) along the caudoventral mandibles, TMJ, tympanic bullae, angular process of mandible, etc. --thickening of the calvarium and tentorium cerebelli -Usually in immature and adolescent dogs --terriers especially -Painful on palpation, even when radiographic changes are not yet present -Start treatment as soon as possible! --corticosteroids and pain control 2-4 weeks
	Sialoceles	-Leakage of saliva through a leak in the salivary duct or gland capsule into submucosal spaces or subcutaneous spaces -Fluid-filled structure in sub-mucocsa or sub-cutaneous tissue -Can be sublingual, pharyngeal, or cervical -Will "bounce" when touched, not neoplasia --filled with fluid -Can be traumatized, needs to be reomved
	Sialocele Treatment	-Remove affected salivary gland -Marsupialization, cut away tissue and suture edges of sialocele to make an opening into the mouth --only effective in 30-40% of patients -Removing the entire affected salivary gland and duct is best approach
	Oral Tumors	-Peripheral odontogenic fibroma -Acanthomatous ameloblastoma -Malignant melanoma -Squamous cell carcinoma -Fibrosarcoma -Malignant peripheral nerve sheath tumor -Osteosarcoma
	Peripheral odontogenic fibroma	-Periodontal ligament tumor -AKA fibromatous epulis or ossifying epulis -Benign -Not causing bone resporption, not inflitrative into bone -Can cause displacement of teeth and malocclusion -Tumor looks like gingiva -Radiographs will show soft-tissue swelling and calcification within the fibroma
	Acanthomatous Ameloblastoma	-Benign tumor, non-metastatic -Most common tumor in dog mouth -Locally very aggressive -Need to treat like a malignant tumor due to local aggressiveness --need to remove with good margins
	Malignant melanoma	-Very bad tumor -Once reach a certain size, probably have metastasized -Can be pigmented or un-pigmented -Can affect gingiva, hard palate, tongue, lips, cheeks, etc.
	Squamous cell carcinoma	-Most common tumor in cats in the mouth --2nd most common in dog mouth -Late metastasis -Can involve large portions of the jaw, highly destructive of bone -Can be very painful
	Fibrosarcoma	-Often seen around muzzle -Easily confused with tooth root abscess -Slowly growing tumor
	Malignant Peripheral Nerve Sheath Tumor	-Grow along larger nerves -Very large tumors -Slow-growing -Need to take deep-tissue samples
	Congenital Palate Defects	-Present at birth -Cleft lip -Cleft hard palate or soft palate -Unilateral soft palate defect -Soft palate hypoplasia
	Acquired palate Defects	-Acquired after birth -Due to severe periodontal disease, trauma, surgery, radiotherapy
	Palate Defect Treatment	-Intense flap surgery or use of grafts needed to fix! -Get help of a professional
	General Considerations for Tooth Extraction	-Exodontics: dental extractions -"Toothanasia," tooth removal is permanent! Cannot go back! -Need to have client's approval -Animal needs to be under general anesthesia, sedation is not enough -Patient needs to be intubated with a tube with inflated cuff -need the right equipment -Dental radiographs are important -Know the correct surgical procedure and flaps
	Indications for Tooth Extraction	-Client preference! (financial reasons) -Periodontal disease -Tooth resorption -Stomatitis -Fractured teeth with pulp exposure -Endodontic/periapical disease -Caries -Persistent deciduous teeth -Malocclusion -Supernumerary teeth -Non-functional malformed teeth -Unerupted teeth-fractures and retained roots -tooth in areas of osteomyelitis or osteonecrosis -Teeth involved with neoplasia
	Contraindications for tooth extraction	-Animals that will not do well under anesthesia -Radiation therapy or chemotherapy, extract tooth before radiation therapy or wait until acute side effects of radiation have disappeared --do not wait too long after radiation therapy, will see change in mucosa -Bleeding disorders -Medication causing prolonged bleeding times
	Keys to success for Tooth Extraction	-Know the anatomy! know where roots run and where teeth should be -Use controlled force and patience --10-second rule -Minimize trauma -Tooth roots should be extracted
	Levers used for tooth extraction	1. 1st class 2. Wedge (most common) 3. Wheel and axle Goal is to rotate to create movement of root segment
	Create space in tooth to insert instrument	-Good for removing tooth -Take a little piece of bone off of the tooth to be removed -Can use lever in newly formed notch/spot -Use burr and remove material from tooth that will be extracted
	Closed tooth extraction	1. Clinically evaluate patient and take radiographs 2. Incise gingival attachment around tooth with a blade or dental luxtor 3. Insert instrument, drive into peridontal ligament space and rotate --hold for 10 seconds --repeat on several sides around the tooth 4. Grasp tooth with extraction forceps as far down on tooth as possible --should not completely close 5. Pull out tooth and examine 6. Debride alveolus, flush extraction site 7. Reduce and shape alveolar bone margin, can interfere with flap closure --can pack alveolus with graft material 8. Suture closed
	Use of graft material	-Expensive -Use in extraction sites if the mandible is thin and risks fracture -Usually not necessary, but good way to make money
	Closed extraction of Multi-rooted teeth	-Have to section tooth to create several single-rooted segments -Use cross-cut fissure bur -Start at furcation area and move towards tip of the crown --take shortest, straightest pathway
	Tooth Sectioning of Maxillary P4	-Upper carnassial tooth -Separate mesiobuccal root from the distal root -Separate mesiobuccal root from mesiopalatal root
	Tooth sectioning of Maxillary M1 and M2 in Dogs	-Section the palatal root from the mesiobuccal root and disrobuccal roots -Separate mesiobuccal and distobuccal root
	Round Burr Sizes to Have	-Used to "shave" bone .25 .5 1 2 4
	Fissure burr sizes to have	-Used to cut through a tooth, section -700 -701 -702
	Round Diamond Burr sizes to have	9 12 14 16 18 23
	Open Tooth Extraction	-Good for difficult extractions --large, solid teeth without periodontal disease --small teeth with long roots --teeth with unusual root anatomy --Root remnants -Unerupted teeth
	Open Extraction Technique	1. Make incision in gingival attachment 2. Make buccal mucoperiosteal flap 3. Remove bone over roots --start with removing 1/3 of the bone, can always take off more --can remove entire alveolar bone, but the less removed the better 4. Section the tooth to make single-rooted segments 5. Elevate and extract crown root segments 6. Debride and close extraction sites --flap needs to be relaxed enough that it can cover the alveolus holes appropriately
	Periosteal elevators	-Flat side faces the bone -Round side faces the conjunctiva -Good for making a flat without tearing the flap
	Alveolectomy	-Removing alveolar bone over root surfaces -Done with round burrs
	Complications with tooth extractions	-Always let the client know if there are complications!! -Fractured roots (most common) -Hemorrhage -Trauma to adjacent structures -Sublingual edema -Sialocele -Orbital trauma -Fracture of the alveolus or jaw -Oronasal communication -Trauma from opposing teeth -Tongue hanging out of the mouth -Emphysema and air embolism -Local and systemic infection
	Canine Tooth Extraction	-Make 2 diverging releasing incisions -Cut into periosteum to free up flap, allow it to be tension free with suture over the wound -Careful about how much force used between 3rd incisor and canine tooth, can fracture bone
	4th premolar Tooth Extraction	-Be careful with distal releasing incision
	Crown	-Covered with enamel
	Root	-Covered with cementum
	Neck of the tooth	-Where cementum and enamel meet -Cemento-enamel junction -Just after the enamel bulge
	Dentin	-Under cementum and enamel in tooth, in both crown and root -Yellow in color -More sensitive than enamel -Thickness depends on age of the patient
	Pulp chamber	-Nerves and vessels of the tooth -Young animals have wide pulp, thin shell structure -older animals have narrower pulp, more shell structure
	Lamina Dura	-Edge of the alveolar socket -White line around the tooth -Connected to cementum by periodontal ligament --allow stretching and moving within the tooth socket
	Apex of the root	-End of the root -Apical delta is the opening where vessels and nerves enter the tooth
	Gingival margin	-Should be pointed, hugging the tooth -Gingival sulcus exists and collects bacteria --floss to remove bacteria --toxins can cause gingiva to become inflamed
	Furcation	-Area of bone between the roots of the teeth -Should come all the way up to the tooth and fill the space -In periodontal disease bacteria collects in sulcus, will destroy bone in furcation area -Check furcation with probe during exam
	Tooth terminology	-Draw line down the middle of the mouth -Mesial: towards the midline -Distal: opposite from midline
	Triadan Tooth System	-Breaks teeth into 4 quadrants -Quadrants are viewed as examiner is facing the patient -Number teeth form midline back -Canine tooth is ALWAYS tooth #4 1: upper right (maxillary) 2: upper left (maxillary) 3: lower right (mandibular) 4: lower left (mandibular)
	Triadan in Dogs	-1 canine in each quadrant -4 premolars in maxilla --P1,2,3,4 -Upper carnassial tooth is always tooth #8 --largest tooth in the upper quadrant -On mandible, carnassial tooth is #9, first molar
	Rule of Carnassials	-Upper carnassial is P4 --Dog: #8 --cat: No maxillary P1, have to count in absence -Lower carnassial is M1 --No P2 or P1 on mandible of the cat, count in absence
	Exam of the Head	-Extraoral -Intraoral soft tissues -Intraoral dental structures -Periodontal evalulation Start outwards and move inwards
	Dental History Questions	-Diet -Home care/brushing --products and methods -Treats --human food? -Toys -Bad habits --human food? --rock eating? --sticks? --separation anxiety habits?
	Dental Chart	-Is a legal document!! -Should be written in ink -Required for every dental patient -Any clinician who completes a dental record must be educated to be able to recognize oral abnormalities! -Have charts for all species
	Extraoral Exam	-Palpate temporal and masseter msucles --feel for atrophy -Look for discharge fro oral, nasal, and ocular surfaces -Check for external lacerations -Lip fold dermatitis -Palpate salivary glands and lymph nodes -Ventral cortex of the mandible -Retropulse eyes, look for symmetry and firmness --look for exophthalmos and enophthalmos --palpate below the eyes -Look in the ears
	Intra-oral exam	-Soft tissues -Dental Structures -Periodontal examination
	Gingiva and mucosa anatomy	1. Mucosa 2. Mucogingival junction 3. Attached gingiva 4. Free gingiva 5. Gingival margin
	Soft tissues in the mouth to look at	-Mucosa and mucocutaneous junction/Mucogingival junction -check for chewing lesions, oral tumors -Look at tongue and vallate papillae -Lingual molar gland -Incisive papilla -Tonsils -Soft palate
	Lingual Molar Gland	-Normal structure in the mouth -contains many little salivary glands -Do not biopsy! unless sick
	Incisive papilla	-Incisive ducts extend to floor of the nasal fossa --ducts enter into vomeronasal organ -Puffy tissue over palatine fissures
	Soft palate Exam	-Under soft palate is the nasal cavity -be sure to palpate!
	Teeth evaluation	-Color in any missing teeth on the chart
	Periodontal exam	-Look at supporting structures of the teeth -Gingiva -Cementum -Alveolar bone and lamina dura -Periodontal ligament attachment apparatus -Describe bone loss
	Periodontal disease	Gingivitis: Gingiva are inflammed --reversible disease Periodontitis: erosion of the gingiva --not reversible
	Periodontal Probe Markings	-Markings on probe for measurement -Want "Michigan O with Williams markings"
	Tooth mobility	-Measured on a scale from 0-3
	Dental probing	-Check sulcus depth --dog: 0-3mm --cat: 0-1mm --Too deep, becomes a "pocket" -note deepest measurement around the tooth
	Gingival recession	-Measure from cemento-enamel junction to the gingival margin
	Gingival hyperplasia	-Gingiva grows over the crown of the tooth -Measure cemento-enamel junction to tip of the tooth (coronally) -Can be drug-induced --Ca channel blockers --cyclosporine --phenobarbital
	Evaluation of dental structures	-Chips, fractures -Alignment -Extrusions -Missing teeth -Root fragments -Caries -Tooth resorptions
	Evaluate occlusion	-Want scissor bite -Lower canine sits between upper incisor and upper canine -Upper carnasial tooth is in front of lower
	Slab fracture	-Can look like calculus on the tooth -Be sure to probe!
	Hypsodont Dentition	-Horse dentition -Long reserve crowns with shot apical ends -Continuous growth and eruption -Wear at occlusal surfaces matches eruption -Large integrated grinding occlusal surfaces -Non-regenerative, do not grow more tooth but push out what tooth they have in reserve -Teeth are continually erupting and constantly wearing at occlusal surface -Older horses have less reserve crown left, have pushed most of it out
	Age changes in the Reserve Crown of horses	-2 year old: LOTS of reserve crown -Less and less reserve crown over time -At 23, basically no reserve crown left --teeth become more fixed in the mouth, slower movement -No reserve crown in older teeth!
	Horse wolf tooth and canine	#4 is the canine, if present #5 is wolf tooth, if present -First 5 teeth have single roots
	Horse cheek teeth	-Have very complicated pulp chambers -Occlusal surface is cementum on outside, then enamel, then dentin in center -Have "lakes" of dentin surrounded by enamel --for infundibula
	Aging a Horse	-Eruption of Deciduous teeth -Eruption of deciduous cheek teeth -Shedding of the deciduous teeth
	Eruption of Deciduous teeth	-Incisors go in 7s -7 days: central incisors have erupted -7 weeks: 2nd incisors are just erupting -7 months: 3rd incisors are erupting
	Eruption of deciduous cheek teeth in horses	-2nd, 3rd, and 4th premolars erupt between birth and 14 days
	Shedding of deciduous teeth	-Shedding of Incisors: --Central incisor sheds at 2 years --2nd incisor sheds at 3 years --3rd incisor sheds at 4 years --incisors are strong indicators of horse's age -Shedding of molars: --2nd premolar: 2.5 years --3rd premolar: 3 years --4th premolar: 4 years -canine teeth: 3-4 years
	Eruption of Permanent teeth	-1st molar: 9-12 months -2nd molar: 2 years -3rd molar: 3.5-4 years -Canine: 4-5 years
	Rules for aging horses	-Horses younger than 2 only have juvenile teeth and 1st molars -Horses older than 5 have all adult teeth -Horses between 5-10 is estimated by looking at wear on occlusal surfaces of mandibular incisors -After 10 years, aging of horses becomes more obscure as horse ages --all bets are off --gets harder the older the horse gets
	Mandibular exostosis	-Bony protrusion -Benign -"Character bumps" -Usually related to exostisos from root tip of tooth --previous injury
	Unilateral nasal Discharge in Horses	-Usually associated with sinus infection --smelly -In chronic cases, hard to treat with medical treatment only -Further diagnostic evaluation is needed
	Tools for a complete oral exam in the horse	-Sepculum -Light source -Examination mirror -Dental probe -Syringe to rinse food material -Examination gloves -Proper restraint
	Internal oral exam in the horse	-Always examine the ENTIRE oral caivty! -Never jump to a diagnosis without looking at the entire oral cavity -Compare right and left arcades, look for asymmetry -Incorporate tactile and olfactory senses into exam
	Additional diagnostic tools in horse dental exam	-CT and radiogaphs -Nuclear scintigraphy -MRI -Ultrasound is not as useful
	Enamel points in Horses	-Normal consequence of time, anatomy, eruption and wear -Found on buccal aspect of the maxillary cheek teeth -Found on lingual aspect of the mandibular cheek teeth
	Wolf Teeth	-Removed for bit placement -Evolutionary "hitchikers" on the horse --used to be a full-blown pre-molar
	Conditions resulting from poor conformation of Horse oral cavity	-Prognathism -Brachygnathism -incisor wear abnormalities -Rostral and caudal hooks -Ramps -Wave mouth
	Underjet vs. underbite	-Underjet: teeth stick out in front of maxillary teeth --based on length of the mandible, mandible is longer than the maxilla --Occlusal surfaces match up -Underbite: occlusal surface of the mandibular teeth is past and higher than the occlusal surface of the maxillary teeth --occlusal surfaces do not match up
	Orthodontics for Horse Overbite	-Goal is to get the mandible to grow forwards --maxillary teeth act as a retainer and prevent growth, need to remove to give mandible a chance to grow -insert a plate
	Equine Surgical Dental Disorders	-Fractured teeth -Pulpal exposure -Periodontal disease -All lead to periapical abscess
	Exodontia	-Removal of teeth -Oral extractions are preferable, have fewer complications -Limited by length and quality of the exposed crown --length of reserve crown --location of tooth to be removed
	Disadvantages of oral extractions in the horse	-Physically demanding -Time consuming -Possible fragmentation of tooth and retained fragments -Damage to adjacent teeth -Restricted access to apical areas or sinus -Need to add a plug to prevent accumulation of food material --will get re-epithelialization and migration of adjacent teeth over the site
	Surgical Exodontia	-Trephine used to punch tooth out from root end -Sinusotomy -Buccotomy -Removal of lateral alveolar plate -Takes a lot longer in a young horse -Will get pieces of teeth, can cause post-operative problems
	Sinusotomy/Trephenation Advantages	-Relatively easy to get tooth out of the mouth -Excellent exposure of the apical area -Improved treatment of a local infection
	Sinusotomy/Trephenation Disadvatages	-General anesthesia is usually needed -Extensive hemorrhage is possible -Infra-orbital canal may be at risk -May remove wrong tooth! -Orosinus fistula may appear and result in chronic sinusitis
	Buccotomy approach for tooth removal	-Remove affected tooth without penetrating the sinus -Generally used for PM4, M1, M2 -Soft tissue anatomical limitations -Limited exposure to apical areas -Does not violate the sinus -Removal of the lateral alveolar plate -If it starts to bleed, surgery is over
	Endodontic Procedures in the Horse	-Root canal therapy is not regularly done -Access to affected pulp canals is limited with apical approaches -Pulp canals are complex and large -Success is limited!
	Dental neoplasia in the Horse	-Cementoma, amesoblastoma, odontomas, papillomas, dental cysts, melanoma in gray horses -Rare in horses, not common at all -Generally slow to develop -Causes mechanical destruction and/or distortion of local tissues
	Equine Tongue trauma	-NOT a restraining device! -Can result in lingual lacerations, foreign bodies, and trauma -Debride and clean the wound -Local or general anesthesia may be needed
	Treatment for Equine Tongue Trauma	-Wound Debridement and cleaning -Local or general anesthesia may be needed, painful fix! -Wound dehiscense is common --local contamination and mobility of tissues --non-compliance of patient during wound healing, patient will use tongue! -Adjust diet to soft feeds -Give wound time
	Salivary gland Lacerations in the Horse	-Repair the duct -Translocate the duct into the mouth -Destroy individual salivary gland that is causing an issue --chemical ablation with injection of caustic solution
	Sialoliths	-CaCO3 accretions -Build up in salivary tissue or salivary ducts -Need to have surgical removal via oral cavity
	Temporal Mandibular Disease in the Horse	-Generally a very reliable horse -Over-diagnosed malady
	Mandibular ossifying Fibroma	-Most common mandibular neoplasia in horses -Locally invasive -Rostral mandibulectomy to treat
	Purpose of the Upper Airway	-Provide patent conduit for rapid flow of large volumes of air to lower respiratory tract -Humidification of air -Temperature exchange -Vocalization -Other factors
	Horse vs. Human upper airway anatomy	-Respiratory demand for horses at rest is very low --create a very small negative pressure when they breathe -Increasing exercise increases demands on respiratory system -Racing involves HUGE volumes of air for the horse
	Horse resting volume of air	-4 liters per second -1 breath every 3 seconds - negative 5 cm H2O
	Horse exercising volume of air	-75 liters per second -1 breath every .5 seconds -negative 40 cm H2O
	General principles of Horse breathing	-Poiseuille's law -Reynold's number -Bernouilli's law
	Airflow Resistance	-Resistance is related to radius --straight laminar flow -Bigger radius of tube has lower airflow -Halving airflow increases resistance 16x -Small changes make big differences in resistance -Ideal is a short, wide tube --will decrease humidity, decrease temperature exchange, increase turbulence --allows body to suck in unwanted things
	Laminar Flow of air	-Laminar flow is better for airway, less turbulence -Reynold's number -Ideal is narrow spaces, low reynold's number --small radius -Small radius also dramatically increases resistance -Balance between laminar flow and resistance
	Air velocity based on pressure	-Air velocity is inversely proportional to pressure -Narrower areas need greater structure/strength to maintain patency of opening --more likely to collapse due to increased pressure on tube -Need complete separation from the GI tract -Complete rigidity would not allow vocalization
	Horse anatomical adaptations in upper airway	-Nostril -Nasal passage -Pharynx -Larynx
	Horse nostrils	-Flexible, incomplete cartilagenous ring -No lateral support, muscles only laterally --at rest do not need big opening, causes more issues --need big opening when there is a need for a lot of iar -Alar cartilage -Dilator muscles help dilate nostrils --levator nasolabialis --dilator naris apicalis --caninus
	Horse nostril flare	-Should not be present at rest -indicates increased pain, endotoxemia, sepsis -During exercise flare is normal, NOT normal during rest
	Horse nasal passage	-Long, rigid meatus with turbinates -Protects upper airway from unwanted objects -Provides humidification -Allows temperature exchange -Laminar flow -"Bucket of blood," very vascular area --allows for humidification and temperature exchange
	Horse nasal turbinates	-Folds of mucosa covered in bone -Breaks airflow into smaller compartments -Allows for laminar flow -Creates more surface area for temperature and humidification changes -Longer nose gives more surface area for exchange
	Nasal Meatuses	-Dorsal meatus, middle meatus, ventral meatus --separated by dorsal and ventral turbinates -Common meatus is the entire thing -Just on other side of meatuses are the dorsal and ventral chonchal sinuses
	Horse Pharynx	-Nasopharynx: above the soft palate -Oropharynx: below the soft palate -Epiglottis should ALWAYS be on top of the soft palate, in nasopharynx, except during swallowing -Pharyngeus muscles allow for vocalizing and swallowing
	Horse as obligate nasal breathers	-More efficient way to breathe -Can more more air through nose efficiently -Humans use mouth to vocalize --mouth is also more efficient based on anatomy for humans -Horses should ALWAYS breathe through the nose!
	Equine displacement of the soft palate	-Epiglottis is moved under the soft palate -"Bag" is now open to the oropharynx -Clinically abnormal -Horses now breathe through mouth and nose together --issue during expiration, prevents horse from getting enough air out during exhalation
	Equine Hyoid apparatus	-Bones extending down from base of skull -Forms "sling" that soft tissues of the pharynx sit in --tent poles -Horses need structural support to hold soft tissues in place during intense breathing
	Equine Larynx	-Cartilages: --arytenoid, cricoid, thyroid, epiglottis --form rigid framework -Go from big opening of pharynx to smaller opening -Needs moving parts, allows vocalization -Narrowest part in upper airway -Cricoarytenoideus dorsalis is main abductor muscle --holds things apart --innervated by recurrent laryngeal nerve
	Recurrent Laryngeal nerve	-Innervates all muscles of the pharynx, including cricoarytenoideus dorsalis -Does NOT innervate cricothyroid, only muscle -Adducts and abducts muscles to create vocalization and open larynx for airway
	Cricoarytenoid Dorsalis Muscle	-Contracts to abduct arytenoid -Opens larynx -If innervation is lost, produces inspiratory problems -In horses, if one side is affected decreases performance -In dogs, only is clinical if bilateral
	Laryngeal grading system	1. Symmetrical, synchronous abduction 2. Asynchrounous opening but full abduction 3. Asynchronous opening with decreased abduction or adduction 4. Paralyzed, no movement Assess relative to the contalateral side
	Upper respiratory disease in the horse	-Respiratory noise -Coughing or dysphagia -Nasal discharge -Facial swelling -Exercise intolerance
	Equine Nasal Discharge	-Unilateral: issue is in respiratory tract --at level of septum or further rostral --purulent discharge: think bacteria -Bilateral: issue is towards the rear of the respiratory tract --esophageal obstruction?
	Making a diagnosis of equine upper respiratory diseases	-Signalment -History: --timing of respiratory noise, at rest or under exercise? --type of respiratory noise -Physical exam --check for symmetrical airflow --laryngeal structure and muscles Common things happen commonly
	Palpation of the Respiratory tract	-Horses may have some previous surgery --good to check! palpate for scars -Palpate muscular processes for laryngeal hemiplegia --unilateral atrophy can be prominent -percussion of sinuses, should be hollow --not the best thing to check -Palpate trachea
	Diagnosis of Equine Upper Respiratory issues	-Standing endoscopic exam is key! -Look for structural and functional abnormalities -Done without sedation, need to look for minor functional changes --sedation changes function -Radiographs and ultrasound can be helpful --sinus abnormalities -CT and MRI -Exercising endoscopy vs. resting endoscopy --look for dynamic obstructions --can be done on treadmill or over ground -Dynamic abnormalities can be hard to find without assessing function
	Ultrasound of the Larynx	-Look for changes in the muscle that indicate recurrent laryngeal nerve atrophy -ALL muscles should be affected except for cricothyroideus muscle -Look for adduction issues first in cricoarytenoideus lateralis muscle --can see more easily
	Dynamic telemetric endoscopy	-Radiotelemetry for endoscope -Can exercise horse on a track and watch the video from a distance -Allows over-ground endoscopy -Can do with all types of performance horses, not just a treadmill --dressage or other types of movements --assess different head and neck positions
	Over ground vs. treadmill endoscopy	-Overground is cheaper -Both are pretty safe -Both have limitations --would not exercise a horse on a treadmill unless they were fit, able to be on the treadmill -Overground endoscopy is harder to control --rider controls the speed --on treadmill, horses run harder and faster
	Nostril lacerations	-Big problem in horses! -Fairly common, horses are curious and spook easily -Not a simple laceration --2 layers, outer skin layer and inner laceration layer -Need to suture BOTH layers for full repair -Ignoring wound and letting it scar prevents dilation of nostril --becomes a functional problem -Can do repair standing with infraorbital nerve block and standing sedation of xylazine
	Alar fold	-Inside tissue of horse "false nonstril" -Causes snoring noise -Common in standarbreds
	Alar fold redundancy	-Pull alar folds out of the way with suture to test and see if fold is responsible for noise or poor performance -Can to surgical resection or excision --70-80% improvement in noise and performance -If nasal passage is narrow, surgery will not help animal
	Equine atheroma	-Cyst within false nostril -Benign -Very far back, does not interfere with the airway -cosmetic, not performance limiting issue
	Wry nose	-Severe congenital deformity of the nostril of a horse -Lateral deviation with rotation -Variable degrees -May be able to correct surgically, may not -Long term respiratory compromise -Changes bone and soft tissue structures in the nose
	Septal abnormalities in the Horse	-Cartilagenous structure separating right and left nares -Infection, previous trauma, neoplasia -Can be unilateral or bilateral abnormality or obstruction -Hard to diagnose endoscopically, give narrow field of view -Radiographs give wider field of view (DV/VD view is best)
	Septal asymmetry	Should cause decreased airflow
	Setpal surgeries	-Will be bloody! --make sure there is a blood cross-match -May need to do tracheostomy, horse will not be able to breathe through nose -Surgery is rarely done -do NOT do surgery in young animals! nose will collapse! --septum is required for normal nostril development and growth
	Progressive Ethmoid hematomas	-Benign hematomas that grow in equine upper airway -Usually cause mild epistaxis, small amounts of bleeding -Blood sacs in nasal passages or sinus, growing sac of clotted blood -Unknown etiology -Older thoroughbreds -Rarely cause facial deformity -Usually unilateral -Can obstruct airflow if they get really big -Can see on endoscopy or radiography -Most commonly grow from ethmoid turbinate region
	Nasomaxillary opening	-At caudal aspect of middle meatus -Opening between nasal passages and sinus -Good spot to look for discharge from sinus into nasopharynx
	Progressive Ethmoid Hematoma Treatment	-control or cure? more often are controlled -Most treated will come back -Can easily treat with formalin injections --takes multiple treatments, regress -Needs to be re-assessed every 6 months or so to look for recurrence -Can do laser ablation/cautery
	Ethmoid Hematoma Summary	-Small volume bleeds -Middle aged horses -TB, arabians -Catch when small -Know if it is in sinus, nasal passage, or both -Recurrence is a concern!
	Paranasal Sinuses	-6 sinuses: -rostral maxillary sinus -Caudal maxillary sinus -Dorsal conchal -Ventral conchal -Frontal -Sphenopalatine -All communicate to go out the nasal maxillary opening
	Paranasal Sinus Disease	-Infection --can be primary or secondary --tooth root abscesses -Paranasal sinus cyst -Neoplasia -Characterize discharge --purulent, bloody (ethmoid hematoma, tumor, fungal disease) -Look for facial deformity (tumor, cyst, infections) -Quidding, dropping food out of mouth
	Primary Sinusitis	-Fluid line, will see fluid radiographically -Lavage and use long-term antibiotics
	Secondary sinustis	-Tooth root abscess -May or may not see fluid -May just see a lot of soft-tissue density --tissue is laid down to wall off abscess -Treat primary problem
	Fluid lines on Radiographs	-Can see in nasal sinuses -Indicates sinusitis of some sort -Lateral radiographs is best view for fluid lines
	Sinus Centesis	-Sampling fluid from sinuses -Need sedation and local nerve block -Go in externally, into caudal maxillary sinus --2cm rostral and ventral to the medial canthus -Make stab incision, feed in catheter or cannula -Leave hole open, is contaminated after incision --can act as drain --easy access to re-lavage -Take cytology, culture, and lavage
	Tooth into ventral turbinate	-Teeth generally break into ventral turbinate -Cause secondary sinusitis
	Paranasal Sinus Cyst	-Benign fluid sac growing in the sinus -Pushes on bone and causes facial deformity -Occurs in young and old horses, less in middle range -Unknown cause, dental origin? -Facial deformity is most common --people can puck up on it -has characteristic fluid
	Paranasal Sinus Cyst treatment	-Debridement -Maxillary or frontomaxillary sinusotomy -With extraction prognosis is excellent! -Cosmetically horse should look normal
	Sinoscopy	-Scoping the sinus -Make a hole in skin and in bone into sinus -Gives great view of paranasal sinuses -Frontal sinus is the biggest space, go into biggest space first -Can use a 2nd portal for other instruments
	Sinus Tumors	-Older horses -Facial deformity -Poor prognosis -Can breath through nasal passage -Biopsy if possible! -Can surgically excise, but better to biopsy to see if treatment with worth it
	Empyema	-Can cause some purulent nasal discharge
	Facial Fractures	-Have to balance cosmetics and function -Can heal will without treatment -Fixing will cause trauma to other tissues in order to heal fracture --sometimes best approach is NOT to treat -Great vascular supply to area provides for incredible remodeling -Surgically be aware of blood supply and foreign material
	Soft tissues keeping airways open	-Pharyngeal muscular force -Suction tries to close airway --breathing through a smaller hole tries to close off more -Neck extension allows more air -Neck flexion decreases air flow
	Assessing Airway Function	-Ability of airway soft tissues to stay open -Standing endoscopy -High speed treadmill and endoscopy -Flow-volume loops -Pressure profiles -Comparison of catheters in pharyngeal and tracheal areas -Help determine if obstruction is detrimental to function or not
	Intermittent Dorsal Displacement of the Soft Palate	-Epiglottis goes under the soft palate -Expiratory obstruction leading to inspiratory compromise -Expiratory gurgle -Exercise induced and intermittent -Can combine with epiglottic entrapment to cause more significant performance problems -Prevents normal expiration, animal can take in less air -Occurs in racehorses and sport horses -"stop, gurgle, chocking down" -Uncommon abnormality -Occurs on EXPIRATION
	Displacement of the Soft Palate	-Epiglottis plays an important role -Nasal occlusion at rest -Evaluating free edge of the palate, look for ulcers -Inflammation and neuritis can be involved -No one thing that tells a horse is displacing the soft palate --hard diagnosis to make
	Managing Dorsal Displacement of the Soft Palate	-Conservative management --non-surgical -Sternothyrohyoideus myectomy -Sternothyroid tenotomy -Staphylectomy, soft palate trim -"Tie forward," keeps tongue forward -Laser palatoplasty -Epiglottic augmentation
	Sternothyrohyoid myectomy	-Cuts muscles that pulls larynx caudally --muscles cannot pull the larynx backwards -Prevents dorsal displacement of the soft palate -Stops epiglottis from being pulled backwards and slipping under soft palate -Not commonly done -Standing outpatient surgery --inexpensive -50% success prognosis
	Sternothyroid tenotomy	-Cuts tendon of sternothyroid muscle right where it attaches to sternothyroid cartilage -Prevents retraction and rotation -Needs to be done under general anesthesia but quick surgery -Quick return to exercise -50% success rate
	Staphylectomy	-Trim some of the soft palate -Have to go in through laryngotomy, ventral approach through cricothyroid space -Creates larger intrapharyngeal ostium --less of an obstruction when palate does displace -Easier to replace the palate once displaced, easier to breathe when displaced -Cutting too big of a hole leads to permanent displacement, gap between nasopharynx and oropharynx -Needs to be done under general anesthesia
	Tie-forward	-Prevents displacement of the soft palate -Sutures between thyroid cartilage and hyoid apparatus -Horses do not displace at speed anymore -Maintains relative relationship between cartilages and thyroid apparatus -80% success rate --horses do not all displace for the same reason
	Cornell Collar	-Holds larynx forward -Horses are less likely to displace their soft palate -Maintains laryngeal position relative to the head of the horse -If horse does not displace with collar on, horse will probably benefit from a tie-forward -Horses can also race in collar, do not need surgery
	Laser induced fibrosis for Dorsal displacement of the soft palate	-Cauderize the dorsal or ventral surface of the soft palate to prevent displacement -Can do surgery standing via endoscope -Fibrosis usually goes away but muscle is still damaged -Questionable efficacy
	Epiglottic augmentation	-treatment for dorsal displacement of the soft palate -Not commonly done anymore -Stiffens epiglottis and prevents dorsal displacement -Expensive -Inject sub-epiglottic tissue that causes granulomatous reaction and leads to stiffening -Can have severe complications if not done correctly -Horse is out of work for months
	Pharyngeal Cysts	-Most often sub-epiglottic -Hard to see -Can cause aspiration in foals -Associated with intermittent displacement of the soft palate -Resect with laser or via snare in mouth, or laryngotomy --great prognosis if cyst can be resected
	Epiglottic Entrapment	-Subepiglottic tissues envelop the epiglottis -Lose scalloped edge and vascular pattern of the epiglottis -Leads to obstruction -Associated with dorsal displacement of the soft palate --can occur together or separately -Can become ulcerated
	Persistent epiglottic entrapment treatment	-Split membrane down the middle -membrane pulls back into a normal position under the epiglottis -Can be done with a laser or manually -Can resect the subepiglottic membranes via laryngotomy, through muscle bellies --distorts normal anatomy, have to resect normal tissues
	Epiglottitis	-Inflammation of the epiglottis -Can cause obstruction -Need to differentiate from entrapment --no free edge, no single membrane, just inflammation -NOT a surgical condition, medical condition -Treat with medical management, steroids
	Axial deviation of the Aryepiglottic folds	-Dynamic abnormality -infolding of membranous tissue across the glottis on inspiration -causes stenosis with each inspiration -"Roarer" like noise during exercise -Narrowing on inspiration -Look normal during resting endoscopic examination -Most common in young thoroughbreds -Can have varying degrees of obstruction, can be unilateral, can be bilateral -Associated laryngeal hemiplegia -Can be due to specific head and neck position
	Axial Deviation of the Aryepiglottic folds Treatment	-Conservative management: --corticosteroids --good prognosis if out of work for several months -Surgical management: --laser resection --no down-side to resection besides cost --get better immediately, time can also be a benefit May be a young horse thing?
	Epiglottic Retroversion	-Rare -Can happen in any age or any breed horse -Inspiratory gurlge -Causes severe respiratory dysfunction -Epiglottis can look normal on resting exam -Epiglottis flips 180 degrees into the pharynx with inspiration -Can be due to upper respiratory infections, damaging surgery -Associated with hypoglossal nerve dysfunction? geniohyoid muscle block or damage due to botched surgery or infection -Associated with other pharyngeal dysfunction
	Treatment for epiglottic retroversion	-Conservative: give time and hope that it gets better --does not work well, probably has some neuromuscular dysfunction -Surgical: --re-create tension of hyoepiglotticus muscle --augmentation --tie-down --resection
	Laryngeal hemiplegia	-Neuropathy of recurrent laryngeal nerve -Affects abduction and adduction -Space gets more and more narrow with exercise and muscle fatigue -Progressive, dynamic, inspiratory collapse --progressive due to muscle fatigue -Causes "roaring" noise -Palpable atrophy of the cricoarytenoideus dorsalis muscle --with atrophy, becomes more prominent -Almost always on the left! -Trauma or malformation if present on the right
	Assessing Laryngeal Function	-Do with endoscopy, standing and endoscopy -Can do with slap test (all or none) --does not test partial function -Nasal occlusion (hard to do) -Swallow reflex -Look for standing abduction and adduction -Do exercising endoscopy -Can look on ultrasound also -Noise + palpable atrophy + asymmetric abduction at rest can give diagnosis
	Ultrasound for Laryngeal hemiplegia	-Look at Cricoarutenoideus lateralis muscle -CAL is abnormal, CAD is also -Good to use when need to compare sides -Hyperechgenicity indicates atrophy
	Layngeal hemiplegia on the right	-Trauma! -Dysplasia, malformation
	Recurrent laryngeal neuropathy	-Nerve issue, structures are fine -Repairing nerve damage will restore function
	Left laryngeal Hemiplegia treatment	1. Benign neglect, change horse's job --not life-threatening issue 2. Remove arytenoid (arytenoidectomy) 3. Re-innervation of cricoarytenoideus dorsalis muscle --not practical yet 4. laryngoplasty, tie-back procedure
	Tie back procedure	-CAD muscle cannot contract to maintain opening -Hold opening patent with suture -Non-absorbable suture between muscular process and cricoid, not into lumen -Tighten arytenoid into abduction -Can combine with vocal cord resection or saccule resection -Do with videoendoscope guidance -Aim for 80-90% abduction --100% will probably cause aspiration problems -Tie cricoid cartilage to muscular process
	Complications with Tie back procedure	-Low complication rate, but it happens -Failure (#1 cause of complications) --a little change in the back with the suture can cause big change at the front, in the airway -Seroma -Infection -Dysphagia -Aspiration via pulling arytenoid too far open -Complication rates are low, but exist -Do not put suture into the airway!
	Treatment of complications with Laryngeal Tie Back	-Failure: repeat tie-back or arytenoidectomy -Infection: drain, give antimicrobials --remove sutures? -Seroma: drain -Dysphagia: remove suture, give animal time
	Arytenoid chondrosis	-Mechanical inhibition of abduction of arytenoids -Arytenoid itself has become abnormal -Thick, misshapen arytenoid -Can be due to ulcerations, granulation tissue -Be sure to differentiate from laryngeal hemiplegia --palpation or ultrasound
	Treatment for Arytenoid chondrosis	-Arytenoidectomy -Requires laryngotomy and tracheotomy -Can do a partial: take almost all of arytenoid but leave a small portion of muscular process -Try to do primary mucosal closure --remove cartilage and put mucosa back --3-sided mucosal flap, remove cartilage and corniculate, then suture back into place -Want to leave as much mucosa as possible but not so much that it flaps into the airway
	Arytenoidectomy prognosis and complications	-Good prognosis, 80% return to racing -60-70% are successful racers --loss of structural support decreases functionality -Increased risk of aspiration
	Guttural Pouch	-Part of the eustacean tube --goes from pharyngeal region up to the ear -Guttural pouch is a big sac within the eustacean tube -MAJOR vessels go through the pouch --get cooled off before blood goes to the brain? prevents brain over-heating? -Exposes large vessels and major nerves to respiratory tract -opened by swallowing
	Nerves in the Guttural pouch	-Vagus -Glossopharyngeal -Hypoglossal
	Guttural pouch anatomy	-Styloid bone splits each pouch into medial and lateral compartments -Medial compartment: internal carotid and cranial nerves -Lateral compartment: external carotid
	Reasons to examine the guttural pouch	-Discharge: purulent or bloody -Neurologic disease --facial nerve -Dysphagia -Respiratory difficulty or swelling
	Guttural pouch tympany	-Guttural pouch fills up with air, acts like a 1-way valve and lets air in but not out -Typically unilateral, although can look bilateral -Common in young TB and arabian foals --rarely if ever seen in adult horses -Empty air sacs on either side o the larynx produces noise -Treat by letting air out --can poke a hole between guttural pouches if only one side is affected --Can make a hole from the pharynx into the guttural pouch -Tympany is relieved immediately with release of air -Holes can re-seal and tympany can recurr
	Salpingo pharyngeal fistula	-Creating a hole between the guttural pouch and the pharynx to treat guttural pouch tympany
	Guttural pouch Empyema	-If fluid: lavage with non-irritating solution -Antimicrobials can be effective -Isolation may be needed --strangles! retropharyngeal lymph nodes just below the guttural pouch swell and burst into the guttural pouch
	Chondroids in the guttural pouch	-Solids in the guttural pouch, solid puss -Can start to push on airway -Surgical condition, have to remove puss accretions -Surgical approach: viborg's triangle, ventral approach, pharyngeal approach
	Temporohyoid osteopathy	-Horse has facial nerve paresis -May also have balance problems -Probably an issue in guttural pouch, right at the base of the skull --temporohyoid joint and periosteal reaction on bone -Causes facial nerve impingement and neuropathy -Can also cause middle ear disease --pushes on nerve and causes neuropathy
	Temporohyoid osteopathy Sequelae	-Very serious! -horse can die! may fracture base of the skull due to fusion of temporohyoid joint -Prevent pulling on stylohyoid bone, separate from the rest of the hyoid apparatus
	Serratohyoidectomy	-Take seratohyoid bone out, remove -Prevents movement at temporohyoid joint that is fused and could cause fracture higher up near brain -Prognosis is excellent for preventing fracture -May not reseolve facial nerve paresis and fracture, less impingement on nerves
	Guttural pouch mycoses	-Fungal infection within the guttural pouch -Looks like proliferative, white, red lesions -In dorsomedial compartment of guttural pouch -Grow based on environmental conditions? --temperature, humidity, and oxygen tension is perfect for growth? -Mycoses can be fatal for the horse!
	Guttural pouch mycosis leading to hemorrhage	-Fungus grows over large vessels in the guttural pouch -Erodes intima, causes hole -MAJOR hemorrhage in carotid artery! -Big flow, large volumes of blood, clotting does not happen easily -Get the horse to a hospital fast!!
	Muscle rupture in Guttural pouch	-Longus capitus muscle can actually be ruptured off of the skull -Horse will be neurologic, can look like mycosis -Horse will be beat-up, needs to have trauma for rupture -No epistaxis
	Purulent guttural pouch mycosis	-Can be just purulent sometimes without hemorrhage -Life-threatening -Big nerves can still be affected by fungus --results in severe pharyngeal dysfunction without a bleed -Horse presents for "choke" -Easy to stop bleeding, hard to stop neurologic dysfunction
	Choke	-Horse has feed coming out of nose bilaterally -Usually due to big bolus of food stuck in esophagus -If it repeats, is probably due to pharyngeal nerve dysfunction
	Recurrent laryngeal neuropathy and pharyngeal dysfunction	-Lesion is in the vagus nerve (recurrent laryngeal nerve) -Vagus nerve is in the guttural pouch, look in pouch for issues!! -Hard to fix!
	Retrograde flow through the carotid artery	-Occurs due to connection to circle of willis -Have to prevent retrograde and anterograde flow
	Occipital vessel	-Comes off of internal carotid and goes to brainstem -Need to make sure the correct vessel is blocked and need to prevent retrograde flow
	Treatment for Internal carotid rupture	-Control hemorrhage -Use balloon in artery to prevent retrograde flow -Ligate normograde flow -Passive correction -Different forms of intraluminal occlusion have been developed to occlude flow with angiogenic catheter -Do not need medical treatment! Just block flow
	Small lesions in the Guttural pouch	-Small lesions cause big problems! -Small fungal lesions in the wrong spot can make horse completely dysphagic -Need to resolve the fungal lesion
	Treatment for Guttural pouch mycosis	-Embolization, air out the guttural pouch -Use laser to superficially ablate the fungus -Allow air into the guttural pouch to change microclimate -Salpingopharyngeal fistula -Medical therapy -Esophagostomy, feed horse until mycosis has resolved -Need to get fungal lesion resolved!! Medical treatment to prevent aspiration is essential
	Guttural Pouch mycosis outcome	-Neurologic deficits are more of a concern! -Life or death situation, needs to be resolved ASAP!
	Jugular vein	-Primary venous access for medications etc. -Common location for persistent phlebitis -Very accessible due to superficial location -has valves that reduce retrograde flow
	Thrombus in jugular vein	-Prevents blood flow from brain back to heart -Can be due to injection of aseptic fluids or catheter placement --catheter becomes nidus for infection -Phenylbutazone perivascular injection causes phlebitis
	Phlebitis on ultrasound	-Hyperechoic flecks due to fibrin and platelets within the vessels -Can perpetuate infection -Can contribute to non-septic thrombophlebitis
	Non-septic thrombophelbitis	-Can fix by alternating injection sites, do not exacerbate the vein
	Septic thrombophelbitis	-Bacteria is involved with thrombus -Need to isolate bacteria and culture -Use ultrasound to find site of thrombus -Avoid injecting anything into vein for as long as it takes to reduce thrombus
	Setons	-Can be gauze -Material placed into an incision as a way to keep it open -Allows incision to heal by 2nd intention
	Esophageal diseases in horses	-Esophageal diseases are rare, difficult to manage -Horse has long esophagus that has small diameter relative to body size --predisposed to developing impaction problems -Horse diet imposes a challenge to management --herbivores, eat bulky feeds and roughage -Horse eats continuously!
	Thrombophelbitis in the horse	-Preventable condition! -Do not use same vein for continual injection
	Equine Impaction	-"Choke" -Usually caused by hay, grain, sugar beet pulp, wood shavings, pellets, fruits or vegetables -Food can absorb water or mucus and expand to clog esophagus -Older horses with poor dental care have harder time crushing and mashing coarse hay -Irregularly shaped objects are less common --fruit pits, corn cobs, wood, wire, deciduous cheek teeth -Medicine boluses can impact esophagus, get lodged
	Predisposing conditions for Impaction/choke	-Communal feeding (faster eating) -Feeding before complete recovery from general anesthesia -Feeding after prolonged or strenuous exercise --especially if water is not available -Fast-eaters, greedy eaters -Pre-existing esophageal condition --ulcer, stricture, tumor, diverticulae
	Impaction/Choke common sites	-Common in areas where there is something pushing on the esophagus -Level of the 2nd cervical vertebra, caudal to the larynx --Wedged between trachea and 2nd cervical vertebrae -At thoracic inlet, where esophagus is bound by 1st rub and the trachea -Segment overlying the base of the heart -Terminal esophagus, lower esophageal sphincter or cardia
	Clinical signs of Impaction/Choke	-Horse looks distressed --walking around the stall -Water and hay material comes out of nostrils (very not normal!) -Dyspnea and coughing, esophagus pushes on the trachea -Can aspirate food material, gets into tracha and lungs and causes pneumonia
	Confirmation of Impaction	-Endoscopy -Most obstructions are between thoracic inlet and mouth -Be sure not to confuse peristaltic waves with actual strictures
	Circumferential esophageal erosion	-Can be due to stricture and feed eroding one spot over time -Can predispose to future strictures and disease
	Treatment of Esophageal Strictures	-Remove food and bedding or muzzle the horse -Pass nasogastric tube, can find where the impaction is generally -Give xylazine sedative, lowers head and prevents aspiration -Lavage impaction when horse is sedated -Allow time for plug to resolve -Repeat treatments! will probably not resolve all at once -If needed, anesthetize, pass endotracheal tube, and lavage esophagus --endotracheal tube acts as conduit, can get food material out -Evaluate mucosa after removal of obstruction, check the damage -Treat inhalation pneumonia and other systemic effects -Re-introduce soft-food diet
	Esophageal Ulcers and Esophagitis	-Caused by prolonged contact with irritants, irritating chemicals -Firm impactions with abrasive materials -Generally circumferential, 360 degrees -Develop in the rostral 10-20 cm of the esophagus --between larynx and thoracic inlet
	Esophagitis and ulcer diagnosis	-Endoscopic exam -Radiographs -Contrast esophagrams, longitudinal folds may appear thickened and tortuous -Easy to confuse normal peristaltic waves with strictures! Both can cause indent in barium column
	Treatment for Esophageal ulcers and esophagitis	-Treat the primary problem --rest esophagus -Feed soft slurries and grass -Can give nutritional support through soft rubber stomach tubes
	Persistent Esophageal Strictures and localized narrowings	-Esophageal myotomy: --find area of stricture and remove muscle that is restricting esophageal mucosa --mucosa can now bulge as needed
	Esophagostomy	-Make a hole into the esophagus, bring out to the skin -Can be used for long-term healing of the esophagus
	Esophageal diverticulum	-Traction diverticulum: due to trauma or injury to esophagus and muscles --outside forces stretch esophagus and cause diverticulum -Polsion diverticulum: Congenitally develops a diverticulum --pressure from within the esophagus allows diverticulum
	Surgery of the Esophagus	-Can have severe complications -Difficult to maintain the size of the lumen -May have lack of a serosa -Movement of neck and esophagus during swallowing needs to be maintained -Ventral approach is recommended -Dehiscence is likely
	Cartilages of the Larynx	-Epiglottis -Thyroid -Cricoid -Arytenoid -Sesamoid -Interarytenoid
	Function of the Larynx	-Movement of air -Vocalization
	Epiglottic cartilage	-prevents fluid and food from going into the airway
	Thyroid cartilage	-largest cartilage in larynx -Incomplete dorsally -U-shape -Landmarks for procedures
	Crioid cartilage	-Only cartialge of the larynx that forms a complete ring -Articulates with thyroid cartilage and arytenoid cartilage -Continues as the trachea
	Arytenoid cartilage	-Paired cartilage -Number of different processes --corniculate --cuneiform --muscular process (CAD muscle attachment) --vocal process
	Lateral Ventricle	-Lined with mucosa -Can protrude into the airway
	Innervation of the Larynx	1. Cranial laryngeal nerve (vagus) --has internal branch: sensory to laryngeal mucosa --external branch: motor to thyropharyngeus muscle 2. Caudal laryngeal nerve (recurrent laryngeal nerve, from vagus) --motor to all intrinsic muscles of the larynx besides for the thyropharyngeus muscle
	Laryngeal paralysis	1. Congenital --breed predisposition --can have central or peripheral nerve abnormalities 2.Acquired (more common) --idiopathic --secondary to trauma --secondary to other diseases --polyneuropathy, myopathy, hypothyroidism, neoplasia --iatrogenic Usually presents as bilateral in dogs
	Layngeal paralysis Signalment	-Large breed dogs are most common -Males more common than females -Middle aged to older dogs -Labrador, afghan, irish setters, goldens, st. bernards -If occurs in young animal, usually is congenital form
	Laryngeal paralysis history	-Change in bark -Inspiratory stridor, exacerbated with heat -Exercise intolerance, weight, heat may exacerbate -Dyspnea -Cyanosis -Gagging -Vomiting -Restlessness, anxiety -Concurrent esophageal disorder -May be asymptomatic at rest
	Laryngeal paralysis physical exam	-Fairly unremarkable, non-specific -Hyperthermia -Continuous panting -May have muscle wasting and weakness if associated with other neurologic signs 0Evaluate laryngeal function under light sedation
	Laryngeal paralysis Diagnostic tests	-CBC and chem are usually normal -thoracic radiographs to look for aspiration pneumonia or megaesophagus -EMG can detect denervation of laryngeal muscles -Histopathology -Evaluate for hypothyroidism
	Medical treatment for Laryngeal Paralysis	-Asymptomatic cases may not need treatment -Weight reduction -Exercise restriction -Alleviate acute respiratory distress --give sedation, corticosteroids, oxygen, cool patient
	Surgery for Laryngeal paralysis	-Do Sx if there is moderate to severe signs -Enlargement of glottic opening can result in aspiration pneumonia --need to avoid aspiration -Usually do a unilateral arytenoid lateralization -Partial laryngectomy -Castellated laryngofissures -Muscle nerve pedicle transposition
	Unilateral arytenoid lateralization	-treatment for laryngeal paralysis -Does not go into lumen of the larynx -Make skin incision just ventral to the jugular groove -Incise and retract subcutaneous tissue and platysma muscle -Retract sternocephalicus muscle and jugular vein dorsally -Palpate dorsal margin of the thyroid cartilage, incise thyropharyngeus muscle right along the thyroid cartilage --arytenoid is deep to the thyroid cartilage -Disarticulate the cricothyroid articulation, transect cricoarytenoideus dorsalis muscle --make prosthetic muscle with sutures -Connect cricoid cartilage to muscular process of arytenoid with suture, takes place of muscle -Opens up arytenoid on one side
	Everted laryngeal saccules	-Component of brachycephalic syndrome -Prolapse of the mucosal lining of the laryngeal crypts, eversion into the airway -Usually a secondary problem -Causes stridulous breathing and respiratory distress, dyspnea -Anesthesia is needed to evaluate the larynx
	Treatment for everted laryngeal saccules	-Just cut them off! -Correct at the same time as treating stenotic nares and soft palate resection
	Laryngeal collapse	-Occurs in animals with brachycephalic syndrome or laryngeal paralysis -History of upper airway rigidity -Animal will have stridor and labored breathing -May show severe respiratory distress -Treat concurrent abnormalities (stenotic nares, elongated soft palate, everted laryngeal saccules) -After collapse, not much to do except permanent tracheostomy --any other treatment can cause webbing across laryngeal opening, acts as obstruction
	3 stages of laryngeal collapse	-Laryngeal saccule eversion -Aryepiglottic collapse -Corniculate collapse
	Trachea	-35 c-shaped hyaline cartilage pieces incomplete dorsally connected by annular ligaments -Dorsal tracheal muscle -Can bend and flex a lot -Surgery is tricky due to segmental blood supply and innervation --shared blood supply with esophagus
	Tracheal Collapse	-Unknown etiology --genetic factors, nutritional factors, allergens, neurologic deficiency, small airway disease, cartilage matrix degeneration -Cartilage becomes hypocellular and degenerates -Trachea becomes flattened -Seen in toy and miniature breeds -In dogs 1-7 years old -Males and females are equally affected
	Tracheal collapse clinical signs	-Often appear before 1 year old -Goose honk cough -Dyspnea -Exercise intolerance -Cyanosis -Syncope -Gagging -More severe with heat, more severe with exercise, more severe with obesity
	Tracheal collapse physical exam	-Evaluate for other underlying issues -Flaccid tracheal cartilages, can feel the edges of the cartilages due to flattening -Auscultation is important to rule out cardiac disease -End expiratory snap due to intrathroacic collapse --cervical trachea collapses in inspiration --thoracic trachea collapses on expiration
	Grade I tracheal collapse	-25% reduction in luminal diameter -Tracehalis muscle is slightly pendulous, protrudes a little bit into the lumen -Cartilages maintain circular shape
	Grade II tracheal collapse	-50% reduction in luminal diameter -Trachealis muscle is more stretched and pendulous -Cartilages begin to flatten
	Grade III tracheal collapse	-75% reduction in luminal diameter -Trachealis muscle is more stretched and pendulous -Cartilages are nearly flattened
	Grade IV tracheal collapse	-Lumen is totally obliterated -Tracheal cartilages are completely flattened -Animal cannot really breathe -Can see on radiograph
	Radiographs for tracheal collapse	-May not see on radiographs if dynamic collapse
	Medical Treatment for Tracheal collapse	-Medical treatment is recommended for patients with mild clinical signs and less than 50% collapse -Antibiotics, anti-tussives, bronchodilators, corticosteroids -Sedation and O2 may be required for acute crises
	Surgical treatment for tracheal collapse	-Good for patients with moderate to severe signs -More than 50% reduction in tracheal lumen -Medical management has failed -Do not delay until animal is severely distressed! -May not be beneficial if there is severe main-stem bronchi collapse as well
	Surgical approach to tracheal collapse	-Put patient directly on back, need to be completely ventral for orientation -Dorsal membrane plication is not common anymore -Place plastic rings to act as external splint --suture rings to outside of the trachea in cervical and proximal thoracic trachea
	internal stents for Tracheal collapse	-Best done on thoracic trachea --thoracic trachea is not a good spot for surgery -Open trachea from the inside, internal opening
	Post-operative care for Tracheal collapse surgery	-Monitor closely during recovery for respiratory distress -Inflammation, edema, and/or laryngeal paralysis can occur -Tie-back procedure may be needed -If laryngeal collapse occurs may need permanent tracheostomy
	Complications for Tracheal collapse surgery	-Occur in immediate post-operative period -Can have stent fractures, stent migration, development of granulation tissue in response to stent -No perfect technique exists
	Temporary Tracheostomy	-Common treatment in small animals -Key is to keep patient completely straight to maintain orientation -Go through annular ligament, cut 1/3 of the way through the trachea -Put stay-sutures in cranial and caudal area, label as cranial and caudal --act as safety net in event that tube comes out -Needs to be suctioned out regularly to remove mucus plug
	Permanent Tracheostomy	-More of a salvage procedure for patients with laryngeal collapse or tumor -Permanent new airway -Split muscle on ventral approach -Bring trachea up to the skin surface and suture muscle to itself under the traceha --also resect any excessive skin, do not want skin to fold into site
	Post-operative care for permanent tracheostomy	-Oxygen -Steroids -Anti-tussives, bronchodilators, analgesics -Exercise restriction for a week post-operatively -Harness -Weight reduction
	Complications for tracheostomy	-Swelling in cervical region -Infection, no larynx or nares to protect the airway -tracheal necrosis -Death -Large mucus production
	Laryngeal tumors	-Lymphosarcoma is most common in the cat -Squamous cell carcinoma -LOTS of other types of neoplasia -Type dictates treatment, important to know what you are dealing with to treat appropriately -Diagnose with laryngoscopy and bronchoscopy, allows biopsy -Treat by resecting part of the trachea
	Laryngeal and tracheal tumor signalment	-Middle aged to older animals -Acute or progressive history of upper airway obstruction -Stridor, dyspnea, cough, voice change -Exercise intolerance, hyperthermia -Gagging, dysphagia, cyanosis, syncope
	Surgical treatment for Laryngeal tumors	-More often than not, cannot surgically treat --tend to be big and in the way -Can be curative if tumor is benign, localized, and small -Malignant tumors may require excision, but rarely possible --may be palliative -Partial or total laryngectomy can be done, but very invasive -Resection and anastomosis for tracheal tumors
	Tracheal Anastomosis	-Can remove 25-50% of the trachea in old dogs --20% in young dogs, more prone to stenosis -Be sure to intubate distal portion of the traceha -Do regular end-to-end anastomosis
	Esophageal Muscular Anatomy	-Dog: 2 oblique layers of striated skeletal muscle throughout the esophagus -Cats: smooth muscle is present in distal 1/2-1/3 of esophagus, skeletal muscle in proximal 1/2-2/3 --skeletal muscle is spiral, forms concentric rings -Can manipulate smooth muscle activity easier than skeletal muscle activity
	Clinical signs of Esophageal disease	-Regurgitation -Hypersalivation -Odynophagia (painful swallowing) -Weight loss due to decreased appetite from painful swallowing or regurgitation -Decreased appetite
	Dysphagia	-Immediate -Never includes bile -Food is never digested -No active abdominal wretch -Hypersalivation is usually present -Often gagging is present -Odynophagia is sometimes present -Multiple swallowing attempts
	Regurgitation	-Time of ejection can be minutes to hours -Bile is rarely involved -Food is sometimes digested -Rarely is there an abdominal wretch -Hypersalivation occurs sometimes -Gagging is present sometimes -Odynophagia is often present -Single or multiple swallowing atempts
	Vomiting	-Reflex initiated in the brain, always involves active abdominal wretch -Occurs minutes to hours after ingestion -Bile is often present -Digested food is often present -Hypersalivation occurs sometimes -Rarely is gagging involved -Odynophagia is never present
	Generalized megaesophagus	-Most common esophageal disease of dogs -Entire esophagus is dilated -Rare in cats -Can be congenital, acquired and idiopathic, or acquired and secondary to something else
	Generalized megaesophagus diagnosis	-History of regurgitation, weight loss, hypersalivation --signs of esophageal disease -Radiographs of neck and thorax --always include the neck in radiographs! -Radiographic change can be subtle or straigh-forward
	Congenital megaesophagus	-Clinical signs in young animals -history of regurgitation -breed predispositions: miniature schnauzer and wire-haired fox terrier --german shepherd, great danes, shar pei, irish setter -Rarely reported in cats -Unknown etiology
	Cause of congenital megaesophagus	-Unknown etiology -Defect in vagal afferent innervation to the esophagus --does not sense distention, no reflex contraction -Inability of the lower esophageal sphincter to open normally
	Diagnosis of Congenital megaesophagus	-history and signs of esophageal disease present since weaning -Survey radiographs -contrast radiography or fluoroscopy is rarely required --contraindicated with megaesophagus is seen on survey radiographs, predisposition to aspiration of barium
	Acquired Secondary megaesophagus	-Lots of diseases and disorders -Most common cause is myasthenia gravis --can be focal and affect only skeletal muscle of esophagus -Hypoadrenocorticism (Addison's disease) -Esophagitis -Esophageal obstruction (should not cause generalized megaesophagus) -Polyneuropathy
	Diagnosing Generalized Megaesophagus	-CBC, chemistry, urinalysis -Thoracic radiographs --tracheal wash if there is evidence of aspiration pneumonia -ACh receptor antibody titer -ACTH stimulation test -Endoscopy can rule out esophagitis, foreign body, neoplasia -Other tests can be done based on clinical suspicion
	Acquired idiopathic Megaesophagus	-Most common form of megaesophagus in dogs -Common in middle aged or older dogs -Large breed dogs -History of regurgitation and cough if there is aspiration pneumonia -Diagnose by finding megaesophagus on survey radiographs --rule out likely causes of secondary megaesophagus
	Supportive Treatment for Megaesophagus	-Provide adequate nutrition! -Feed in upright position -High calorie, low fat diet --fat decreases gastric emptying time, increases gastric acid production -Gastrotomy tubes can be placed in animals that cannot get adequate nutrition, last option
	Medical treatment for Megaesophagus	-basically treat esophagitis -Sucralfate 500mg, 1g PO as slurry --binds to ulcerated areas of mucosa and prevents further damage --helps control and prevent esophagitis -Decrease gastric acid production --H2 blockers (famotidine, ranitidine, cimetidine) --proton pump inhibitors (omeperazole)
	Prokinetic agents as treatment for Megaesophagus	-Not effective for the dog, no smooth muscle in dog esophagus -Metoclopramide may increase tone of lower esophageal sphincter --may also worsen esophageal emptying --not recommended
	Megaesophagus Prognosis	-Congenital form has fair prognosis -20-40% spontaneously recover with management -Prognosis for acquired secondary megaesophagus depends on underlying disease --myasthenia gravis, 50/50 --addison's responds well to treatment -Acquired idiopathic megaesophagus has guarded to poor prognosis --no spontaneous recovery --dogs die from recurrent aspiration pneumonia
	Most common lung lobe for aspiration pneumonia	-Right middle lung lobe -Overlies the heart
	Esophageal Foreign Body	-Usually bones, rawhides, chew toys in dogs -Toys or hairballs in cats -Animal will regurgitate and hypersalivate -May be acute, or may be days-weeks with partial obstruction --can still occur with long history of regurgitation -Diagnose with survey neck and thorax radiographs -May need contrast study, use iodine instead of barium due to possibility for perforation -Endoscopy provides definitive diagnosis
	Treatment for Esophageal Foreign Body	-Remove as soon as possible! medical emergency! -Endoscopic removal is ideal --can either pull our or push into the stomach --gastrotomy is better than esophagotomy -Esophagotomy has poor prognosis, will have higher chance for stricture at site of surgery -Consider gastrostomy tube for esophagitis -Anti-inflammatory drugs can prevent stricture formation at site -Withhold food after removal?
	Esophageal Foreign Body Prognosis	-Generally good -Depends on how much damage has been done at time of removal -Have risk of perforation and stricture formation
	Esophagitis	1. Caused by reflux of gastric acid -Can be due to persistent vomiting, abnormal lower esophageal sphincter function, prolonged anesthesia 2. Pressure necrosis from esophageal foreign bodies 3. Chemical injury 4. Infectious agents 5. Drugs (docycycline in cats, clindamycin)
	Clinical signs of Esophagitis	-Regurgitation -Anorexia, not wanting to eat -Lots of time diagnosis is based on clinical suspicion -May be a difficult diagnosis -Endoscopy can be done to look for inflammation --severe cases have mucosal hyperemia and ulceration --mild cases may appear grossly normal -Biopsy is needed for definitive diagnosis
	Esophagitis Treatment	-Sucralfate slurry -Antacids -Nutritional changes --withhold feed for a little bit --feed low-fat diet --gastrostomy tube in severe cases -Broad spectrum antibiotics in severe cases -Severe cases may require hospitalization and supportive care
	Esophagitis Prognosis	-Excellent prognosis in mild cases -Guarded to poor prognosis in severe cases -Stricture formation is most common complication -Perforation and bacterial translocation can be complications
	Esophageal Stricture	-Caused by circumscribed esophagitis, fibrosis associated with healing of esophagitis -Can be post-operative -Mass lesions (neoplasia, abscess, granuloma) -Looks like usual esophageal disease --regurgitation, pain on swallowing
	Esophageal stricture diagnosis	-Survey radiographs: may see partial dilation --not definitive diagnostic test -Contrast radiographs are usually needed to confirm diagnosis -Ultrasound or CT may help to find extraluminal mass lesions -Endoscopy is definitive diagnosis
	Treatment for Esophageal Stricture	-Esophageal balloon dilation -Withhold food for 24-72 hours -Treat esophagitis with sucralfate or antacids -Anti-inflammatory drugs may prevent re-stricture -Surgery is not a good option
	Prognosis for Esophageal Stricture	-Fair to guarded prognosis -Required dedication of owner, multiple balloon dilation procedures are often needed --on average 2-3 dilations are needed, up to 20 -Esophageal perforation can happen with balloon dilation -Malignant strictures have grave prognosis

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