The pathogenesis of equine laryngeal hemiplegia — a review

Influence of unilateral and bilateral vocal cordectomy on airflow across cadaveric equine larynges at different Rakestraw grades of arytenoid abduction

Objective

To assess the effect of vocal cordectomy on airflow across equine larynges at different Rakestraw grades of arytenoid abduction using a unidirectional airflow model.

Study design

Ex vivo, repeated measures.

Sample population

Twenty cadaveric equine larynges.

Methods

The right arytenoid cartilage was maximally abducted in all larynges. Each larynx was assigned a Rakestraw grade A or B, and the left arytenoid was abducted accordingly. Each larynx was tested under 3 conditions: intact, left vocal cordectomy (LVC), and bilateral vocal cordectomy (BVC). Translaryngeal pressure and airflow were measured, and digital video footage was obtained. Translaryngeal impedance (TLI) was calculated, and the arytenoid left‐to‐right quotient angle (LRQ) and rima glottis cross‐sectional area (CSA) were measured from standardized still images.

Results

Vocal cordectomy reduced TLI by 14.5% in LVC in comparison with intact larynges at Rakestraw grade B (P = .014). In Rakestraw grade A position, neither unilateral nor bilateral vocal cordectomy had any effect on TLI. Regardless of Rakestraw allocation, both LVC and BVC increased CSA in comparison with intact larynges (P < .005), with BVC larynges experiencing a greater effect than LVC (P < .0001).

Conclusion

Using a unilateral airflow model, LVC improved TLI in larynges where arytenoid position approximated Rakestraw grade B. However, when the arytenoid position approximated Rakestraw grade A, there was no effect on TLI following LVC or BVC.

Clinical significance

Surgeons considering a vocal cordectomy should take into account the degree of arytenoid abduction before performing the procedure, as it may not be warranted from a TLI point of view.

Assessing pathological changes within the nucleus ambiguus of horses with recurrent laryngeal neuropathy: An extreme, length-dependent axonopathy

INTRODUCTION

Equine recurrent laryngeal neuropathy (RLN) is a naturally occurring model of length-dependent axonopathy characterized by asymmetrical degeneration of recurrent laryngeal nerve axons (RLn). Distal RLn degeneration is marked, but it is unclear whether degeneration extends to include cell bodies (consistent with a neuronopathy).

METHODS

With examiners blinded to RLN severity, brainstem location, and side, we examined correlations between RLN severity (assessed using left distal RLn myelinated axon count) and histopathological features (including chromatolysis and glial responses) in the nucleus ambiguus cell bodies, and myelinated axon count of the right distal RLn of 16 horses.

RESULTS

RLN severity was not associated with RLn cell body number (P > .05), or degeneration. A positive correlation between the left and right distal RLn myelinated axon counts was identified (R² = 0.57, P < .05).

DISCUSSION

We confirm that RLN, a length-dependent distal axonopathy, occurs in the absence of detectable neuronopathy.

Pathological classification of equine recurrent laryngeal neuropathy

Recurrent Laryngeal Neuropathy (RLN) is a highly prevalent and predominantly left-sided, degenerative disorder of the recurrent laryngeal nerves (RLn) of tall horses, that causes inspiratory stridor at exercise because of intrinsic laryngeal muscle paresis. The associated laryngeal dysfunction and exercise intolerance in athletic horses commonly leads to surgical intervention, retirement or euthanasia with associated financial and welfare implications. Despite speculation, there is a lack of consensus and conflicting evidence supporting the primary classification of RLN, as either a distal ("dying back") axonopathy or as a primary myelinopathy and as either a (bilateral) mononeuropathy or a polyneuropathy; this uncertainty hinders etiological and pathophysiological research. In this review, we discuss the neuropathological changes and electrophysiological deficits reported in the RLn of affected horses, and the evidence for correct classification of the disorder. In so doing, we summarize and reveal the limitations of much historical research on RLN and propose future directions that might best help identify the etiology and pathophysiology of this enigmatic disorder.

Prevalence of upper respiratory diseases and associated factors in Colombian Creole horses

ABSTRACT To determine the prevalence of diseases of the upper respiratory tract and associated factors in the Colombian Creole Horse Valley Aburrá in 2015, a random sampling of 15 farms in southern Aburrá Valley under different management conditions was performed. A total of 105 CCC underwent general clinical examination, respiratory endoscopic evaluation and a detailed inspection of housing conditions and management. A low prevalence of upper respiratory tract diseases was observed, including Pharyngeal Lymphoid Hyperplasia 38.1%, Recurrent Laryngeal Neurophaty 12.38%, Dorsal Displacement of the Soft Palate 7.62%, and presence of tracheal secretions not associated with a specific pathology. A bivariate analysis showed association between tracheal secretions and frequency of training per week (OR = 9.86), duration of the training sessions (OR = 5.55) and inadequate ventilation of the stable (OR = 10.52). Association between HLR and inadequately ventilated barns was also observed (OR = 14.9). Logistic regression showed association between tracheal secretions and inadequate ventilation (OR = 7.18). We conclude that inadequate ventilation was the most important factor for the incidence of upper respiratory tract diseases in horses at the southern area of the Aburrá Valley.

Fifty years of recurring struggles with recurrent laryngeal neuropathy

Recurrent laryngeal neuropathy appears to be a simple problem that should have a simple solution, yet the complexity and dynamic nature of laryngeal function is underappreciated. This review highlights the challenges and accomplishments that work towards that greater understanding of what is necessary to find a successful solution.

Ultrasound-guided biopsy of the cricoarytenoideus lateralis muscle: technique and safety in horses

REASONS FOR PERFORMING STUDY

Current diagnosis of recurrent laryngeal neuropathy (RLN) depends upon disease recognition in the clinically affected horse. Biopsy of the intrinsic laryngeal muscles may provide a method to identify the changes in fibre-type composition that occur in RLN before clinical signs become apparent.

OBJECTIVE

To develop an ultrasound-guided biopsy technique of the left cricoarytenoideus lateralis muscle (CALM) and evaluate its efficacy and safety in vivo.

STUDY DESIGN

A longitudinal descriptive study.

METHODS

Six standing horses underwent ultrasound-guided biopsy of the left CALM. Frozen muscle cores were obtained with a breast biopsy tool. Serial endoscopic, ultrasonographic and physical examinations before and for 8 weeks after the biopsy were assessed for iatrogenic trauma. Histologies of representative muscle core cross-sections were analysed for the total number of muscle fibres obtained with each biopsy.

RESULTS

There were no immediate complications of the procedure and the left CALM was harvested in all instances. Biopsy samples had an average weight of 0.043 g (range = 0.023-0.077 g) and contained 3418 fibres in cross-section (range = 711-7143). Laryngeal endoscopic grade did not change significantly between prebiopsy and the end of the 8 week follow-up. The left CALM had significantly greater echogenicity than the right throughout the study (P<0.001), but there was no difference between the prebiopsy CALM echogenicity and that at completion of the study.

CONCLUSIONS

Ultrasound-guided biopsy of the left CALM is safe and well tolerated, providing a minimally invasive method to obtain muscle from healthy horses. This new technique may be applicable in research and clinical settings.

Videoendoscopic evaluation of the upper respiratory tract in 93 sport horses during exercise testing on a high-speed treadmill

REASONS FOR PERFORMING STUDY

Videoendoscopy of the upper respiratory tract (URT) during high-speed treadmill exercise has proved to be invaluable in the assessment of URT dysfunction in racehorses. However, very little information exists regarding dynamic airway collapse in other sport horses used in nonracing equestrian disciplines.

OBJECTIVES

To evaluate the videoendoscopic findings at rest and during exercise in a mixed population of sport horses referred for investigation of poor athletic performance and/or abnormal respiratory noise.

METHODS

Videoendoscopy of the upper airway was performed at rest and during high-speed treadmill exercise in 93 horses.

RESULTS

Dynamic airway obstructions were diagnosed in 77% of horses and were frequently complex in nature. The most common forms of dynamic collapse included soft palate dysfunction (54%), dynamic laryngeal collapse (38%), axial deviation of the aryepiglottic folds (24%) and pharyngeal wall collapse (18%). In the majority of horses, no obvious abnormalities were identified at rest. Enforced poll flexion was found to be a contributing factor in 24% of cases.

CONCLUSIONS

Dynamic obstructions of the URT were a common cause of poor performance and/or abnormal respiratory noise in sport horses referred for investigation of performance problems.

POTENTIAL RELEVANCE

This study highlights the importance of videoendoscopic evaluation of the URT during exercise in horses utilised for equestrian sports where exercise during competition is submaximal in nature.

Immunohistochemical analysis of laryngeal muscles in normal horses and horses with subclinical recurrent laryngeal neuropathy

We used immunohistochemistry to examine myosin heavy-chain (MyHC)-based fiber-type profiles of the right and left cricoarytenoideus dorsalis (CAD) and arytenoideus transversus (TrA) muscles of six horses without laryngoscopic evidence of recurrent laryngeal neuropathy (RLN). Results showed that CAD and TrA muscles have the same slow, 2a, and 2x fibers as equine limb muscles, but not the faster contracting fibers expressing extraocular and 2B MyHCs found in laryngeal muscles of small mammals. Muscles from three horses showed fiber-type grouping bilaterally in the TrA muscles, but only in the left CAD. Fiber-type grouping suggests that denervation and reinnervation of fibers had occurred, and that these horses had subclinical RLN. There was a virtual elimination of 2x fibers in these muscles, accompanied by a significant increase in the percentage of 2a and slow fibers, and hypertrophy of these fiber types. The results suggest that multiple pathophysiological mechanisms are at work in early RLN, including selective denervation and reinnervation of 2x muscle fibers, corruption of neural impulse traffic that regulates 2x and slow muscle fiber types, and compensatory hypertrophy of remaining fibers. We conclude that horses afflicted with mild RLN are able to remain subclinical by compensatory hypertrophy of surviving muscle fibers.

Placement of a long term tracheal cannula in a Thoroughbred racehorse with bilateral laryngeal dysfunction

A Thoroughbred horse with bilateral laryngeal dysfunction was treated by placement of a long term tracheal cannula in order to restore full athletic function. The horse initially presented with right-sided arytenoid dysfunction that was considered to be due to a congenital malformation of the laryngeal cartilage. This was corrected by a right-sided laryngoplasty and ventriculectomy. The horse re-presented 1 year later with idiopathic left laryngeal hemiplegia. The decision was made to place a long-term tracheal cannula due to the low success rate and high complication rate associated with other surgeries used to correct bilateral arytenoid dysfunction. A three-piece tracheotomy cannula and stopper were positioned under general anaesthesia. The horse rapidly adjusted to the tracheal cannula and no post-surgical complications were encountered. The horse resumed training 4 weeks postoperatively. Due to the rules governing racing in Australia the horse was exported to New Zealand where he continued his racing career. It was concluded that tracheotomy is a straightforward technique associated with minimal complications and can provide an excellent prognosis for return of full airway function in racing horses. It is recognised that many issues need to be considered prior to more general acceptance of this technique, including assessment of animal welfare issues and public perception. In appropriate cases consideration should be given to using long term placement of a tracheotomy cannula as a treatment option to restore maximal airflow in horses with upper airway obstruction.

Tracing axons of peripheral nerves in rats: a potential technique to study the equine recurrent laryngeal nerve

To study the fascicular anatomy of peripheral nerves, three different groups of retrograde axonal tracers were evaluated: fluorophores, horseradish peroxidase conjugated to subunit B of cholera toxin (CT-HRP), and adeno-associated virus (AAV). The hindlimb nerves in rats served as a model to identify the most efficient tracer in regard to labeling axons within peripheral nerves. The rat's tibial and common peroneal nerves were injected with the different tracers and the sciatic nerve was subsequently examined for evidence of labeled axons. The CT-HRP clearly provided the best results in this rat model. Subsequently, CT-HRP was injected into the recurrent laryngeal nerve (RLN) of two horses in order to identify the location and distribution pattern of the RLN axons within the course of the cervical vagus nerve trunk. No labeling could be observed in either of the two horses.

Laryngeal paralysis: a study of 375 cases in a mixed-breed population of horses

Referred cases (n = 375) of laryngeal paralysis (1985-1998) from a mixed-breed equine population included 351 (94%) cases of recurrent laryngeal neuropathy (RLN) (idiopathic laryngeal hemiplegia) and 24 cases (6%) of laryngeal paralysis from causes other than RLN. Laryngeal movements were classified endoscopically into one of 6 grades, in contrast to the usual 4 grades. The RLN cases had a median grade 4 laryngeal paralysis, of which 96% were left-sided, 2% right-sided and 2% bilaterally affected. RLN cases included 204 (58%) Thoroughbred, 96 (27%) Thoroughbred-cross, 23 (7%) draught, 16 (5%) Warmbloods and 10 (3%) other breeds, including only 4 (1%) ponies. The median age of RLN cases at referral was 6 years (range 2-12) and their median height was 170.2 cm. The work of RLN horses included National Hunt racing (42%), flat racing (1%), hunting (19%), eventing (16%) and miscellaneous work (22%). Reported presenting signs in RLN-affected horses included abnormal exercise-related respiratory sounds in 90% and reduced exercise tolerance in only 64%. However, many horses were referred before their exercise tolerance could be fully assessed. Forty percent of the RLN cases had intercurrent disorders, including 10% with additional upper respiratory and 7% with lower respiratory tract diseases. The 24 nonidiopathic RLN cases included 12 with bilateral laryngeal paralysis, 11 (92%) of which were ponies. Bilateral laryngeal paralysis occurred with hepatic encephalopathy in 7 cases and following general anaesthesia in 2 cases. The 12 cases of acquired unilateral laryngeal paralysis included 7 caused by guttural pouch mycosis.

Clinicopathological features of equine primary hepatic disease: a review of 50 cases

The clinicopathological features of 50 cases of equine hepatic disease were reviewed. There was a wide range of clinical signs and at least 50 per cent of the animals exhibited either dull demeanour, anorexia, abdominal pain, cerebral dysfunction and/or weight loss. Life-threatening complications of hepatic failure recorded were: gastric impaction in 10 cases, bilateral laryngeal paralysis in seven cases and coagulopathy in five cases. All the cases had high activities of gamma-glutamyl transferase (GGT) and most had high activities of glutamate dehydrogenase (GLDH) and high concentrations of bile acids. Fewer of the horses had abnormal concentrations of bilirubin, albumin and globulin. The horses that were euthanased or died had significantly higher concentrations of GGT, GLDH and bile acids than the survivors. There were biochemical data for 18 cases with signs of hepatic encephalopathy, all of them had plasma ammonia levels greater than 90 micromol/litre but this was not significantly correlated with the clinical severity of the condition. Half of the cases with hepatic encephalopathy were hyperglycaemic, none was hypoglycaemic, and none had abnormally low levels of plasma urea.

Blood gas tensions, acid-base status, heart rates, and venous profiles in exercising horses with laryngeal hemiplegia before and after corrective surgery

The physiologic effects of exercise were studied in four horses with complete laryngeal hemiplegia. Right carotid arteries were surgically elevated to a subcutaneous position for percutaneous catheterization. Each horse was fitted with a device designed to obtain multiple arterial samples while the horse was exercised over a 1.6-km course. After each horse completed 10 test gallops, the laryngeal hemiplegia was treated using a laryngeal prothesis and ventriculectomy. The horses were then reconditioned, and the exercise test and sampling were repeated. Horses with laryngeal hemiplegia became acidotic, hypoxic, and hypercapnic compared to normal horses. Surgical treatment improved blood gas and acid-base status, but the values were not equivalent to those in normal horses similarly tested.

Determination of the early age of onset of equine recurrent laryngeal neuropathy. 1. Muscle pathology

The age of onset of equine recurrent laryngeal neuropathy has not been ascertained, although the clinical condition of left laryngeal hemiplegia ("roaring") has been recognized for centuries. The purpose of this study was to evaluate the laryngeal muscles of draft horse foals for the presence of fiber-type grouping, indicating denervation and reinnervation, and to determine if histological evidence of recurrent laryngeal neuropathy was present. Abductor and adductor laryngeal muscles from the left and right sides were collected immediately after euthanasia from male draft horse foals, six less than 2 weeks and four 6 months of age, and stained for myosin ATPase. A morphometric test was used to objectively evaluate several areas from each muscle for fiber-type grouping. Extensive fiber-type grouping which was characteristic of recurrent laryngeal neuropathy was found in one of the young foals and all of the older foals. Four of the young foals had some areas of fiber-type grouping suggestive of mild, early changes associated with recurrent laryngeal neuropathy. One of the young foals had no fiber-type grouping present in any of the laryngeal muscles evaluated. These findings suggest an early age of onset of recurrent laryngeal neuropathy.

Effects of left recurrent laryngeal neurectomy, prosthetic laryngoplasty, and subtotal arytenoidectomy on upper airway pressure during maximal exertion

Upper airway pressure was measured with a nasotracheal catheter system and a portable pressure transducer in 10 normal horses during maximal exercise before and after left recurrent laryngeal neurectomy. Measurements were repeated 16 weeks after prosthetic laryngoplasty (5 horses) or subtotal arytenoidectomy (5 horses). During maximal exertion, prosthetic laryngoplasty was more effective than subtotal arytenoidectomy in reversing the increases in upper airway pressure that followed left recurrent laryngeal neurectomy.