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What's New in Head and Neck Surgery

of the Dog
M. J. Bojrab, DVM, MS, PhD, Larry A. Nafe, DVM

Some of our readers may wonder at the subject of this article, and TRACHEAL COLLAPSE
think that it somehow crept into the wrong journal. However, every Incidence
now and then it seems good policy to lift one's eyes from the work at
A number of cases of trachéal collapse in the dog have
hand to appreciate the breadth of influence of the modern suppor¬
tive techniques that we have become familiar with. Increased been recorded. Baumann (1941)' was the first to describe
future communication between the disciplines of veterinary and the condition. No further reports were published until 1960,
human surgery can lead to nothing but benefit to both parties.- when Leonard- mentioned a case. Since that time, over 40
Richard Warren, MD cases of trachéal collapse have been reported.:1 The cause of
collapsed trachea is unknown. Although obesity and head
conformation have been mentioned as predisposing causes,
\s=b\ Major surgical procedures in veterinary medicine have it is usually described as an acquired lesion found in
increased in sophistication and number. An area that has middle-aged dogs of miniature and toy breeds.1 In these
received much attention recently is surgery of the head and neck cases, there is no loss of potential trachéal ring size,
of the dog. This article discusses some new techniques that have
although the rings do lose their ability to remain firm, and,
gained popular usage in recent years. Repair of tracheal subsequently, collapse. To date, there is no published
collapse, treatment of salivary mucoceles, pharyngostomy, and information to our knowledge on the chemical contents of
atlantoaxial subluxation are the procedures reviewed.
trachea! rings in dogs with normal vs collapsed tracheas.
(Arch Surg 112:1013-1018, 1977) This condition has also been described in young dogs as a
congenital lesion.
progressed tremendously in the
surgery has Clinically, both the acquired and congenital conditions
Veterinary
past
seeking
are
increasing number of veterinarians
ten years. An
advanced training in veterinary surgery. The
have the same presenting signs.5 The condition causes
respiratory embarrassment due to dorsoventral narrowing
recent trend toward specialization is reflected in the of the trachéal lumen. Its major pathological feature is a
growth of membership in the American College of Veteri¬ weakened, flaccid trachealis muscle and annular trachéal
nary Surgeons. This specialty group, founded in 1965 by a ligaments that connect the cartilaginous rings dorsally in a
few charter members, presently has over 100 members. bowstring effect. This weakening and stretching of the
Paralleling this increased interest in surgery as a specialty soft tissues allow the rings to flatten and the trachea to
is an increase in the veterinary literature of new surgical assume a lunate rather than circular shape (Fig 1). The

techniques, as well as modifications of existing surgical major clinical sign associated with trachéal collapse is a
techniques. This article discusses a few techniques that continual honking cough. In severe trachéal collapse, the
have recently gained widespread utilization in appropriate animal may have persistent respiratory infections. The
canine cases. diagnosis is confirmed by palpation of the cervical trachea,
tracheoscopy (endoscopie), and cervical as well as thoracic
roentgenograms." These roentgenograms must be taken on
Accepted forpublication Dec 23, 1976. both inspiration and expiration in order to illustrate the
From the Department of Veterinary Medicine and Surgery, College of
Veterinary Medicine, University of Missouri, Columbia (Dr Bojrab), and the trachéal collapse."
Animal Medical Center, New York (Dr Nafe).
Reprint requests to Veterinary Teaching Hospital; Department of Medi- Indications
cine and Surgery; College of Veterinary Medicine; University of Missouri,
Columbia, MO 65201 (Dr Bojrab). Surgical correction is currently being performed on only

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soft tissue of the trachea with polyester suture material
(Fig 3 and 4).s" An antibiotic treatment regimen that was
chosen by presurgical sensitivity testing should be started
24 hours before surgery and continued for five days
postoperatively.
If the cough persists postoperatively, an antitussive
agent should be used to prevent damage to the suture line.
Exercise and excitement should be minimized until healing
has taken place (14 to 21 days). In the event the cartilagen-
ous rings also become flaccid, the previously described
technique will not be successful. In this case, 0.5 cm wide,
C-shaped polyurethane prosthetic rings are implanted and
sutured on the outside of the trachea. They are placed
approximately 1 cm apart for the entire distance of the
collapse.12
SALIVARY MUCOCELE
Incidence
Clinically, the most common injury to the salivary gland
in the dog is salivary mucocele.1' The sublingual gland is
most frequently involved. This condition develops from a
leakage of saliva into surrounding tissue due to damage to
the salivary gland or duct. The most frequent sites for
collection of the extravasated saliva are the sublingual
tissue on the floor of the mouth on one side of the tongue,
and the superficial connective tissues of the intermandib¬
ular or cranial cervical area. The cause of the gland or duct
damage is rarely known. Foreign body or trauma or both
have been suggested as possible causes. The incidence of
this condition is relatively low: in one study of approxi¬
Fig 1.—Top trachea demonstrates lunate appearance of mately 4,000 dogs presented to a university veterinary
collapsed trachea in cross section. Lower cross section
represents normal trachea. Units shown are metric (from Rubin et hospital, only one case of this condition was diagnosed.14
al6). However, the condition is important because of its intract¬
able nature.
those animals that do not respond to conservative treat¬
ment. It is important that the cases selected for surgery be
Indications
carefully evaluated. Many dogs exhibiting signs of trachéal Treatment directed at the mucocele, such as its surgical
narrowing have other underlying pulmonary or cardiac resection, chemical cautery of its lining, or aspiration of
problems that either interfere with correction or must be the fluid, will frequently result in recurrence of the lesion.
stabilized before correction is undertaken. It is believed Because a ránula will often become traumatized by teeth,
that unrelieved trachéal narrowing can cause hypoxia, and and because a pharyngeal mucocele can result in respira¬
the hypoxia may result in cardiac, pulmonary, or CNS tory obstruction, these lesions should always be treated
disturbances. definitively. Since the lining of the mucocele is not secre¬
There have been at least five methods for trachéal repair tory, and thus the saliva is coming from a ruptured
reported in the literature.61" One more recent technique sublingual or mandibular duct, the definitive surgical
that we have used successfully in a number of cases where treatment is directed at the removal of the involved
the cartilagenous rings have maintained their structural salivary glands and draining or aspirating the muco¬
integrity is the method of plicating the dorsal trachéal cele.1417 These two glands are intimately associated, and
ligament. This procedure shortens the gap between the thus are removed as a unit.
free ends of the trachéal cartilage and corrects the dorso- A 4- to 6-cm incision is made over the easily palpated
ventral collapsing of the trachea. The trachea is mandibular salivary gland, caudal to the angle of the
approached from a ventral midline incision in the cervical mandible (Fig 5). The thin cutaneous platysma muscle is
region extending from the larynx to the thoracic inlet. The incised to reveal the capsule of the mandibular salivary
paired sternohyoideus muscles are separated the length of gland, which is also penetrated. An Allis tissue forceps is
the incision to expose the trachea. The trachea is freed used to retract the salivary gland through the incision.
from the surrounding connective tissue by blunt dissection Blunt and sharp dissection of the sublingual gland is
and is rotated so that the dorsal surface is accessible (Fig continued rostrally between the masseter and digastric
2). Starting from the cranial trachéal region, horizontal muscles (Fig 6).15'718 A hemostat is placed across the most
mattress sutures are placed 0.5 cm apart through the dorsal rostral portion of the sublingual duct that can be exposed

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Fig 4.—Repaired trachea showing mat¬
tress sutureplacement (from Rubin et
*J- uu- al6).

Fig 2.—Plication of dorsal soft tissue struc¬ Fig 3.—Representation of mattress suture
ture with Allis tissue forceps to determine placement in trachea (from Rubin et al6).
amount of eversión required (from Rubin
et al6).

Fig 5.—Lateral view of head of dog. Skin Fig 6.—Mandibular salivary gland is Fig 7.—Hemostat is placed across sublin¬
incision (arrow) for salivary gland resec¬ grasped with Allis tissue forceps and gual gland as far rostrally as possible prior
tion is shown in relation to mandibular sublingual salivary gland is dissected with to ligation (from Harvey16).
salivary gland (from Harvey16). Metzenbaum scissor (from Harvey16).

(Fig 7). Care is taken to make sure that the rostral rapid, and consists of making an incision caudal to the
polystomatic sublingual glands are retracted and removed. angle of the mandible into the pharyngeal recess (Fig 8). A
The duct is then ligated rostral to the hemostat with 2-0 flexible plastic tube is then grasped with forceps and
chromic gut, and the duct is then replaced in the incision. drawn into the pharynx through the incision. The
The subcutaneous tissue and skin are closed in the normal previously measured tube is passed down to the stomach
manner.1" and the external end is sutured to the skin of the pharyn¬
The mucocele itself is aspirated or drained by a ventral gostomy incision (Fig 9).s·21-' The tube must project only a
incision to remove the accummulated saliva. Postoperative few centimeters exterior to the incision. Capping of the
care consists of supportive treatment. tube when not in use is necessary to avoid loss of gastric
contents and inflow of air. The skin edges of the incision
PHARYNGOSTOMY TUBE will begin to granulate, but will not close due to the
Anorexia is a serious complication of many diseases of presence of the tube. However, once the tube is removed,
dogs and cats seen by the veterinary practitioner. Labora¬ healing is rapid, and rarely does the incision require
tory dogs and cats often become stressed from shipping, surgical closure.
and upper respiratory infections develop and they stop
BULLA OSTEOTOMY
eating. The success of the treatment regimen often is Incidence
dependent on fulfilling the nutritional needs of the animal
until the specific therapy becomes effective.-" In these Ear infection is widespread in the canine population
animals, a pharyngostomy tube is indicated, through which throughout the world. It has been reported at one univer¬
the caloric requirements can easily be administered. sity veterinary teaching hospital that one out of eight
Other indications for a pharyngostomy tube are postop¬ animals brought to the hospital are clinically affected with
eratively, after oral or esophageal surgery, and to remove otitis.-4
gas fluid accumulation from the stomach, such as in the
or Otitis media in the dog is commonly caused by an
gastric dilation and torsion syndrome. The technique is extension of otitis externa. Often, standard medical treat-

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Stylohyoid
Epiglottis
s Thyrohyoid

Thyroid cartilage
*ç~ Cricoid cartilage
Trachea

Fig 8.—Proper placement of finger lateral to hyoid apparatus


(from Bohning8).
Fig 9.—Tube in position within pharynx and esophagus (from
Bohning").
ment (systemic antibiotics, myringotomy, and flushing) of Oseeus Bullo
the otitis media is not satisfactory. At this point, surgical
intervention is indicated in order to gain access and
drainage to the area.-4-7 Although there are three Hypoqloasai
techniques of bulla osteotomy in common use in veterinary
medicine, the ventral approach is becoming the most V- Sublingual CjlancL
popular.-4·-7 In this procedure (the ventral diverticulum of
the middle ear cavity just rostral to the mastoid), the bulla
is reached between th digastric and the styloglossus muscle
(Fig 10, top) through a skin incision lateral to the larynx.
Care should be taken to isolate and retract the hypoglossal
nerve medially. When the bulla has been exposed, it is
opened with a bone chisel (Fig 10, bottom) or trephine, and
at this point a culture of the contents can be obtained.
Further treatment depends on the type of lesion revealed
and the results of the culture. Often, a drainage tube is
placed from the opened bulla to the outside. The surgical
site is then closed in the routine manner.-5 Daily flushing
down the external ear through the myringotomy and out
the bulla drain is continued until improvement is noted
(five to seven days).
ATLANTOAXIAL SUBLUXATION
In recent years, atlantoaxial subluxation has been recog¬
%*>
nized with increasing frequency in the dog.-s Atlan¬ ;"

toaxial subluxation may result in dorsal displacement of


Fig 10.—Top, Surgical exposure of ventral aspect of osseous
the axis, with severe spinal cord compression.-" The most bulla. Bottom, Bulla has been opened with bone chisel to expose
common cause of atlantoaxial subluxation and subsequent middle ear cavity (from Spreull27).
spinal cord compression is the congenital absence of the
odontoid process or dens (Fig ll).38 The other two predis¬ 22-gauge orthopedic) (Fig 14 through 17). Also, some
posing factors are the rupture of the ligaments that hold experts believe that decompression of the cord is indicated,
the odontoid process in place (Fig 12) and a fracture of the and they achieve this by removal of bone from the caudal
dens (Fig 13).-* Surgical correction must be immediate arch of the atlas and from the cranial wall of the axis.28 The
because of the vital areas of the spinal cord involved. The wire must be very tight to prevent any movement that
joint is approached from the dorsal midline through the might eventually shear the wire. The incision is closed in a
intervening epaxial muscles. The actual technique varies suitable manner.
between surgeons, but the goal is to stabilize the joint These animals require careful postoperative observation,
dorsally with heavy, malleable stainless steel wire (20- to and should be confined to an intensive care unit after the

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fa

Fig 11.—Congenital absence of odontoid Fig 12.—Rupture of ligaments with sublux¬ Fig 13.—Fractured odontoid process with
ation of atlantoaxial joint. Arrows indicate subluxation of atlantoaxial joint. Arrows
(dens) with lack of joint support and abnormal rotational relationship between indicate abnormal rotational relationship
subluxations. Arrows indicate abnormal
rotational relationship between atlas and atlas and axis (from Gage28). between atlas and axis (from Gage28).
axis (from Gage28).

Fig 14.—Threading of double strand of wire under dorsal arch of


atlas and dorsal to spinal cord to emerge at foramen magnum.
Note that a hemilaminectomy has been performed (from
Fig 15.—Loop of wire has been pulled cranially to sufficient length
Gage28). to reachcaudally to axis (from Gage28).

Fig 16.—Two drill holes being placed in dorsal spine of axis (from
Gage28).

Fig 17.—Completed operation showing double wire technique for


reduction and stabilization (from Gage28).

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operation. Postoperative therapy utilizes glucocorticoids to surgery are ventral
decompression of the cervical spinal
decrease spinal cord edema and inflammation that could cord, cricopharyngeal myotomy, corrective otoplasty,
cause severe respiratory depression. Many surgeons surgical correction of primary and secondary cleft palate,
combine diuretic therapy with the cortico steroids to and cervical vertebral fusion utilizing a rib graft.
control the edema. Physical therapy should begin on the The other regions of the body have also paralleled these
third postoperative day and continue until the animal is advances with new methods. Cryosurgery, among other
ambulatory. The duration of recovery depends on the modes of surgery, has surfaced, and is now popular use for
severity of the condition and the degree of irreversible cord specific conditions, especially superficial neoplasms. The
damage present, as well as the delay prior to surgical instrumentation utilized by veterinary surgeons is more
intervention. sophisticated, and therefore the results are more satisfac¬
tory. Other interesting procedures just being introduced
COMMENT are the adaptation of human knee prosthesis to the canine
stifle, a new hip prosthesis, and radical trachéal resection
The above techniques represent a few of the many that and anastomosis. Through continuing research, clinical
have gained popular use recently in canine surgery. Other trials, and comparative studies, veterinary surgery will
techniques now utilized with frequency in head and neck continue to progress.

References
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