Upper airway function during maximal exercise in horses with obstructive upper airway lesions. Effect of surgical treatment

A clinical case of a subepiglottic cyst in a Japanese Black calf

A 36-day-old Japanese Black calf exhibited wheezing associated with dyspnea from birth. Arterial blood gas analysis revealed a low oxygen partial pressure of 51 mmHg, low oxygen saturation of 83%, and high carbon dioxide partial pressure of 58.8 mmHg. Computed tomography, endoscopy, and ultrasonography showed cyst formation under the epiglottis. When the cyst was aspirated under ultrasonic guidance to secure the airway, 30 ml of viscous white turbid content was aspirated. The cyst shrank immediately after aspiration, but the wheezing and respiratory symptoms resumed 7 days after aspiration. Therefore, the cyst was surgically removed from the ventral side of the neck. No cyst remodeling was observed 30 days after surgical removal.

Computed tomographic geometrical analysis of surgical treatments for equine recurrent laryngeal neuropathy

OBJECTIVES

To characterize the 3-D geometry of the equine larynx replicating laryngeal hemiplegia and 4 surgical interventions by use of CT under steady-state airflow conditions. Secondly, to use fluid mechanic principles of flow through a constriction to establish the relationship between measured airflow geometries with impedance for each surgical procedure.

SAMPLE

10 cadaveric horse larynges.

PROCEDURES

While CT scans were performed, inhalation during exercise conditions was replicated for each of the following 5 conditions: laryngeal hemiplegia, left laryngoplasty with ventriculocordectomy, left laryngoplasty with ipsilateral ventriculocordectomy and arytenoid corniculectomy, corniculectomy, and partial arytenoidectomy for each larynx while CT scans were performed. Laryngeal impedance was calculated, and selected cross-sectional areas were measured along each larynx for each test. Measured areas and constriction characteristics were analyzed with respect to impedance using a multilevel, mixed-effects model.

RESULTS

Incident angle, entrance coefficient, outlet coefficient, friction coefficient, orifice thickness, and surgical procedure were significantly associated with upper airway impedance in the bivariable model. The multivariate model showed a significant influence of incident angle, entrance coefficient, and surgical procedure on impedance; however, the orifice thickness became nonsignificant within the model.

CLINICAL RELEVANCE

Laryngeal impedance was significantly associated with the entrance configuration for each procedure. This suggested that the equine upper airway, despite having a highly complex geometry, adheres to fluid dynamic principles applying to constrictions within pipe flow. These underlying flow characteristics may explain the clinical outcomes observed in some patients, and lead to areas of improvement in the treatment of obstructive upper airway disease in horses.

Ex vivo evaluation of arytenoid corniculectomy, compared with three other airway interventions, performed on cadaveric equine larynges with simulated recurrent laryngeal neuropathy

OBJECTIVE

To compare laryngeal impedance, in terms of air flow and pressure, following arytenoid corniculectomy (COR) versus 3 other airway interventions (left-sided laryngoplasty with ipsilateral ventriculocordectomy [LLP], LLP combined with COR [LLPCOR], and partial arytenoidectomy [PA]) performed on cadaveric equine larynges with simulated left recurrent laryngeal neuropathy (RLN) and to determine whether relative laryngeal collapse correlated with the interventions performed.

SAMPLE

28 cadaveric equine larynges.

PROCEDURES

Each larynx in states of simulated left RLN alone and with airway interventions in the order LLP, LLPCOR, COR, and PA was evaluated in a box model construct that replicated upper airway flow mechanics consistent with peak exercise in horses. Results for impedance, calculated from airflow and pressure changes, were compared between states for each larynx. Multivariable mixed-effects analysis controlling for repeated measures within larynx was performed to calculate the predicted mean impedance for each state.

RESULTS

Results indicated that tracheal adapter diameter, individual larynx properties, airway intervention, and relative laryngeal collapse affected laryngeal impedance. The LLP and LLPCOR interventions had the lowest impedance, whereas the COR and PA interventions did not differ substantially from the simulated left RLN state. Residual intraclass correlation of the model was 27.6 %.

CONCLUSIONS AND CLINICAL RELEVANCE

Although impedance was higher for the simulated left RLN with the COR intervention state than with the LLP intervention state, given the clinical success of PA for treating RLN in horses and the similar results for the COR and PA intervention states in the present study, the use of COR warrants further investigation. The residual interclass correlation suggested that individual laryngeal variation affected impedance and may have a clinical effect.

Race performance following epiglottic entrapment surgery in Thoroughbred yearlings

BACKGROUND

Epiglottic entrapment can occur in yearling Thoroughbreds (TB); however, race performance following surgical correction is unknown.

OBJECTIVES

To determine the race performance of horses treated surgically for epiglottic entrapment as yearlings as compared to an untreated cohort. A second objective was to identify risk factors for treated horses not racing post-operatively.

STUDY DESIGN

Retrospective cohort and case-control studies.

METHODS

Medical (1989-2014) and race records of 66 treated TB racehorses were reviewed. Observed abnormalities on pre- and post-operative endoscopic images and surgical method were recorded. Race records (EquineLine) were recorded. Racing performance of treated yearling TBs and two of their maternal half-siblings, which were used as the untreated cohort, was evaluated in a cohort study. A case-control study was used to investigate risk factors for not racing post-operatively among treated horses. Quarterly starts and earnings were compared to an untreated cohort. Survival analysis was used to assess career longevity. Rates of racing and earnings were compared between groups using Poisson and negative binomial regression respectively. Associations between clinical variables and not racing post-surgery were evaluated using logistic regression.

RESULTS

Sixty-six treated horses were identified, 65 of which had at least one half-sibling. Proportions of horses that raced were similar for treated and maternal cohorts (70.0 vs. 70.8%, P = 0.9). Treated horses performed similarly to untreated horses. In treated horses, epiglottic entrapment with abnormal right arytenoid movement was associated with never racing (OR 15.40, 95% CI 1.64-144.23, P = 0.02). More females were affected by epiglottic entrapment than males (47/66 vs. 19/66 respectively, P<0.001).

MAIN LIMITATIONS

The retrospective design over a prolonged period of time with cases obtained from a single hospital population. Low case numbers likely influenced the outcome of the multivariable analysis.

CONCLUSIONS

Thoroughbred racehorses treated in their yearling year for epiglottic entrapment had no differences in performance variables compared to their untreated cohort. Epiglottic entrapment with abnormal right arytenoid movement might decrease odds of racing post-operatively.

Respiratory diseases and their effects on respiratory function and exercise capacity

Given that aerobic metabolism is the predominant energy pathway for most sports, the respiratory system can be a rate-limiting factor in the exercise capacity of fit and healthy horses. Consequently, respiratory diseases, even in mild forms, are potentially deleterious to any athletic performance. The functional impairment associated with a respiratory condition depends on the degree of severity of the disease and the equestrian discipline involved. Respiratory abnormalities generally result in an increase in respiratory impedance and work of breathing and a reduced level of ventilation that can be detected objectively by deterioration in breathing mechanics and arterial blood gas tensions and/or lactataemia. The overall prevalence of airway diseases is comparatively high in equine athletes and may affect the upper airways, lower airways or both. Diseases of the airways have been associated with a wide variety of anatomical and/or inflammatory conditions. In some instances, the diagnosis is challenging because conditions can be subclinical in horses at rest and become clinically relevant only during exercise. In such cases, an exercise test may be warranted in the evaluation of the patient. The design of the exercise test is critical to inducing the clinical signs of the problem and establishing an accurate diagnosis. Additional diagnostic techniques, such as airway sampling, can be valuable in the diagnosis of subclinical lower airway problems that have the capacity to impair performance. As all these techniques become more widely used in practice, they should inevitably enhance veterinarians' diagnostic capabilities and improve their assessment of treatment effectiveness and the long-term management of equine athletes.

Assessment of the efficacy of composite surgery for the treatment of dorsal displacement of the soft palate in a group of 53 racing Thoroughbreds (1990-1996)

REASONS FOR PERFORMING STUDY

There has been no objectively assessed case-control study of the efficacy of surgery to correct dorsal displacement of the soft palate (DDSP) previously reported.

HYPOTHESIS

Composite surgery has a beneficial result on racing performance in horses affected with DDSP as compared to a matched control population.

METHODS

Race records were obtained for 53 racing Thoroughbreds which underwent composite staphylectomy, sternothyrohyoideus myectomy and ventriculectomy for correction of idiopathic DDSP at the University of Bristol between 1990 and 1996. Each surgical case was matched for age, sex and training yard with 2 control horses. The racing performance, based on prize money won, of surgical cases and control horses were compared for 3 races run before and after the date of surgery.

RESULTS

Ninety-two percent of the surgical cases returned to racing after surgery. There was a significant increase in earnings of the surgical group before and after surgery (P = 0.011), but there was no significant difference in earnings of the control group before and after the date of surgery (P = 0335). Sixty percent of the surgical group had higher earnings after surgery than before, compared to 40% of controls. When horses which underwent surgery were ranked relative to their 2 matched controls, surgical cases did not significantly change in rank (P = 033), whereas control horses significantly decreased in rank (P = 0.012). Additionally, horses within the surgical group were more likely (P < 0.01) to start in 3 post operative races than those in the control group.

CONCLUSIONS AND POTENTIAL RELEVANCE

Composite surgery had a beneficial effect on racing performance of horses afflicted with idiopathic DDSP, and further studies to evaluate objectively the usefulness of other surgical techniques are warranted.

Effect of laryngoplasty on respiratory noise reduction in horses with laryngeal hemiplegia

REASONS FOR PERFORMING STUDY

Laryngoplasty is the technique of choice for treatment of laryngeal hemiplegia, with the aim of improving airway function and/or eliminating respiratory noise. However, there are no quantitative data in the literature describing the effect of laryngoplasty on upper airway noise or its relationship to upper airway mechanics in horses with laryngeal hemiplegia.

OBJECTIVES

To determine whether laryngoplasty reduces respiratory noise in exercising horses with laryngeal hemiplegia; and to establish whether the degree of upper airway obstruction can be predicted by upper airway noise, or the degree of arytenoid abduction correlated with airway obstruction and noise production.

METHODS

Six Standardbred horses with normal upper airways during maximal exercise were used. Respiratory sounds and inspiratory transupper airway pressure (Pui) were measured in all horses before and after induction of laryngeal hemiplegia and 30, 60 and 90 days after laryngoplasty. Inspiratory sound level (SL) and the sound intensity of the 3 inspiratory formants (F1, F2 and F3, respectively) were measured using a computer-based sound analysis programme. The degree of abduction was graded by endoscopic visualisation 1, 30, 60 and 90 days post operatively. Linear regression analysis was used to determine correlations between Pui, sound indices and grades of arytenoid abduction.

RESULTS

In laryngeal hemiplegia-affected horses, Pui, inspiratory SL and the sound intensity of F1, F2 and F3 were significantly increased. At 30 days following laryngoplasty, the sound intensity of F1 and Pui returned to baseline values. The sound intensities of F2, F3 and SL were significantly improved from laryngeal hemiplegia values at 30 days post operatively, but did not return to baseline at any measurement period. Sound level, F2 and F3 were significantly correlated with Pui (P<0.05), but the correlations were weak (r2 = 0.26, 035 and 0.40, respectively). Grade of abduction and F2 were positively and significantly correlated (P<0.006, r2 = 0.76). Grade of arytenoid abduction and Pui were not correlated (P = 0.12).

CONCLUSIONS

Laryngoplasty reduced inspiratory noise in laryngeal hemiplegia-affected horses by 30 days following surgery, but did not return it to baseline values. While upper airway noise and Pui were correlated, this relationship was insufficiently strong to predict Pui from noise in individual animals. The degree of arytenoid abduction was not correlated with Pui, but was positively correlated with noise production.

POTENTIAL RELEVANCE

Laryngoplasty reduces upper airway noise in horses with laryngeal hemiplegia, but is not as effective as bilateral ventriculocordectomy in this regard, although respiratory noise reduction occurs more rapidly than with bilateral ventriculocordectomy. Residual noise during exercise cannot be used as a predictor of improvement in upper airway function in individual horses following laryngoplasty. The degree of arytenoid abduction obtained following surgery does not affect upper airway flow mechanics. Interestingly, we found that the greater the arytenoid abduction, the louder the respiratory noise.

Prevalence of pharyngeal and laryngeal abnormalities in Thoroughbreds racing in Australia, and their association with performance

REASONS FOR PERFORMING STUDY

Little information is available regarding the prevalence of abnormalities of the upper airway and their association with performance in the general population of Thoroughbred racehorses.

OBJECTIVES

To describe the prevalence of selected abnormalities of the upper airway and their association with performance in Thoroughbred racehorses in Australia.

HYPOTHESIS

That abnormalities of the upper airway of Thoroughbred racehorses are associated with poor race performance.

METHODS

Rhinolaryngoscopy was performed after racing and presence and characteristics of abnormalities of the larynx and pharynx were recorded in a prospective cross-sectional study of Thoroughbred horses racing in Victoria, Australia.

RESULTS

Rhinolaryngoscopy was performed once on each of 744 horses over 35 months. Fifty abnormalities of the upper airway were detected in 47 horses (6.3%, 95% confidence interval [CI] 4.7-83%). Epiglottic entrapment was detected in 7 horses (0.9%, 95% CI 0.4-1.9%) and was significantly (P = 0.015) associated with superior performance. Grade 2 asymmetry (4 grade scale) of the left arytenoid cartilage was detected in 9 horses (1.2%, 95% CI 0.5-2.4%) and was also associated with superior performance (P<0.001). Ulceration or erosion of the mucosa of the axial surface of one or both arytenoids was detected in 18 horses (2.4%, 95% CI 13-3.8%) and was not associated with alterations in exercise performance (P = 0.31).

CONCLUSIONS

Epiglottic entrapment, Grade 2 laryngeal asymmetry and mucosal erosions detected in Thoroughbred racehorses were not associated with impaired performance; therefore, surgical correction and concern over laryngeal function in horses with Grade 2 asymmetry may not be necessary in individuals performing to expectation.

Subtotal or partial unilateral arytenoidectomy for treatment of arytenoid chondritis in five calves

CASE DESCRIPTION

5 calves were evaluated for abnormal respiratory noise associated with variable degrees of respiratory distress.

CLINICAL FINDINGS

Tachypnea and inspiratory dyspnea were detected at initial evaluation in all calves. Endoscopic evaluation of the upper respiratory tract revealed enlarged and immobile arytenoids. Radiographic (n = 3) and computed tomographic (1) evaluation of the laryngeal area revealed images that were indicative of a large soft tissue mass at the level of the arytenoids obstructing the rima glottis. A presumptive diagnosis of arytenoid chondritis was made.

TREATMENT AND OUTCOME

A tracheostomy tube was placed in all calves. Medical treatment (with antimicrobials and anti-inflammatory drugs) was attempted in 4 calves after initial evaluation. Unilateral arytenoidectomy via a laryngotomy was performed under general anesthesia in all calves. Dysphagia and coughing were the most frequent postoperative complications. Three calves survived at least 6 months after the procedure. One calf died of a perforated abomasal ulcer 3 months after the surgery. Another calf died suddenly 1 month after the surgery of an undetermined cause.

CLINICAL RELEVANCE

Unilateral arytenoidectomy was a viable surgical treatment for arytenoid chondritis in calves. Further research in a larger number of affected cattle is needed to determine the advantages or disadvantages of this procedure over other surgical techniques.

Effect of adipose-derived mesenchymal stem and regenerative cells on lameness in dogs with chronic osteoarthritis of the coxofemoral joints: a randomized, double-blinded, multicenter, controlled trial

Autologous stem cell therapy in the field of regenerative veterinary medicine involves harvesting tissue, such as fat, from the patient, isolating the stem and regenerative cells, and administering the cells back to the patient. Autologous adipose-derived stem cell therapy has been commercially available since 2003, and the current study evaluated such therapy in dogs with chronic osteoarthritis of the hip. Dogs treated with adipose-derived stem cell therapy had significantly improved scores for lameness and the compiled scores for lameness, pain, and range of motion compared with control dogs. This is the first randomized, blinded, placebo-controlled clinical trial reporting on the effectiveness of stem cell therapy in dogs.

Performance after Partial Arytenoidectomy without Mucosal Closure in 27 Thoroughbred Racehorses

OBJECTIVE

To examine the effect of partial arytenoidectomy without mucosal closure on postoperative racing performance and long-term complications in Thoroughbred racehorses treated for laryngeal hemiplegia, arytenoid chondropathy, or failed laryngoplasty.

STUDY DESIGN

Retrospective study.

ANIMALS

Twenty-seven Thoroughbred racehorses.

METHODS

Medical records of Thoroughbred racehorses that had partial arytenoidectomy without mucosal closure between 1992 and 2002 were reviewed. Horses were divided into groups: horses that had not raced (Group 1) and those that had raced (Group 2) before surgery. Lifetime race records were compared between groups. A standard starts index (SSI) and performance index (PI) were used for Groups 1 and 2, respectively, to objectively evaluate each horse's postoperative performance. Telephone interviews of owners and trainers were used for subjective performance evaluation and to determine prevalence of long-term complications.

RESULTS

Eleven (61%) Group 1 and 7 (78%) Group 2 horses raced and earned money after surgery. All Group 1 horses that raced performed at a level lower than the national average. Only 1 Group 2 horse had an improved PI score postoperatively.

CONCLUSIONS

Thoroughbred racehorses have a fair prognosis for racing successfully after partial arytenoidectomy without mucosal closure.

CLINICAL RELEVANCE

This technique may be a practical alternative to primary mucosal closure, would decrease surgical time, and avoid some problems reported with primary mucosal closure.

Laryngoplasty with ventriculectomy or ventriculocordectomy in 104 draft horses (1992-2000)

OBJECTIVE

To evaluate efficacy and safety of laryngoplasty with vetriculectomy (VE) or ventriculocordectomy (VCE) for treatment of laryngeal hemiplegia (LH) in draft horses.

STUDY DESIGN

Retrospective study.

SAMPLE POPULATION

One hundred four draft horses used for competitive hitch competitions.

METHODS

Medical records and postoperative endoscopy for competitive hitch draft horses diagnosed with left LH and treated with laryngoplasty and VE or VCE between January 1992 and December 2000 were reviewed. Follow-up information was obtained from telephone interviews with owners and trainers, and performance scores of 1 to 3 were assigned in which 1 was defined as a horse that was unable to perform (abnormal respiratory noise with or without exercise intolerance), 2 was able to perform but not for its intended use (exercise tolerant but abnormal respiratory noise), and 3 was performing as expected for its intended use (exercise tolerant, no abnormal respiratory noise).

RESULTS

One hundred four horses that had 111 laryngoplasty procedures were included. All horses had preoperative performance scores of 1. Follow-up information was available for 79 horses. Improvement in postoperative performance (exercise tolerant, with or without abnormal respiratory noise) was reported in 92% of horses. Respiratory noise was eliminated in 72% (57 horses) of horses. Postoperative performance scores were the following: 3 in 57 (72%) horses, 2 in 16 (20%) horses, and 1 in 6 (8%) horses. There was no significant difference in postoperative performance based on preoperative grade of LH. There was a trend for horses with >/=70% of possible maximal abduction postoperatively to have a performance score of 3. Postanesthetic complications included prolonged recovery (4 horses, 4%) and myopathy or neuropathy (7 horses, 7%). One of these horses was killed because it did stand; triceps myopathy and encephalopathy were confirmed on necropsy.

CONCLUSIONS

Laryngoplasty with VE or VCE is an effective and safe procedure for the treatment of LH in the draft horse. Repeat laryngoplasty can be performed successfully, with good performance outcome after laryngoplasty failure. Complications associated with general anesthesia and laryngoplasty in draft horses are higher than reported for light breed horses under similar conditions.

CLINICAL RELEVANCE

For LH, laryngoplasty with VCE or VE under general anesthesia is recommended to eliminate abnormal respiratory noise and improve performance in most competitive hitch draft horses.

Disorders of the larynx

The upper respiratory tract is a frequent cause of exercise intolerance in horses, particularly in racing horses. There are a myriad of laryngeal abnormalities that may restrict airflow at the rima glottidis. Careful endoscopic examination is a crucial part of the examination of any racing horse suffering from poor performance. There has recently been interest in spectrum analysis of respiratory sounds. It has been determined that laryngeal hemiplegia and dorsal displacement of the soft palate have unique sound patterns. Therefore, spectrum analysis of respiratory sounds may prove to be useful in the diagnosis of laryngeal disorders in horses. Accurate diagnosis and appropriate surgical intervention are necessary to provide the horse the best chance of returning to its full athletic potential.

Diagnosis of upper respiratory tract diseases in the performance horse

Wastage of performance horses because of respiratory dysfunction is common. Appropriate identification of the disease is paramount for treatment recommendations. Diagnostic modalities for upper respiratory tract dysfunction include a thorough physical examination, radiographic evaluation when appropriate, and upper respiratory tract endoscopy. Anatomical deviations or structural are easily identified during resting evaluation, while exercise testing is often necessary to assess thedynamic properties of the upper airway. Utilizing the many diagnostic tools available allows the clinician to make an accurate diagnosis and recommend appropriate treatment.

The effect of recurrent laryngeal neurectomy in conjunction with laryngoplasty and unilateral ventriculocordectomy in thoroughbred racehorses

OBJECTIVE

To investigate the effects of recurrent laryngeal neurectomy (RLN) in combination with laryngoplasty and ventriculocordectomy on the postoperative performance of Thoroughbred racehorses treated for grade III left laryngeal hemiparesis (LLH).

STUDY DESIGN

Retrospective study.

SAMPLE POPULATION

Fifty-five Thoroughbred racehorses.

METHODS

Medical records for Thoroughbred racehorses treated surgically by laryngoplasty and laser ventriculocordectomy with or without RLN between June 1993 and December 1996 were reviewed. Outcome was evaluated subjectively by assessment of performance obtained from telephone interviews with owners and trainers, and objectively by assessment of racing performance for 3 races before and after surgery using a performance index (PI).

RESULTS

Fifty-five Thoroughbred racehorses with resting endoscopic grade III LLH were treated by laryngoplasty and ventriculocordectomy either with (39 horses) or without (16 horses) RLN. For RLN horses, respondents for 38 horses believed performance was improved in 19 horses, unchanged in 16 horses, and decreased in 3 horses. For horses without RLN, respondents for 9 horses reported that performance was improved in 5 horses, unchanged in 2 horses, and decreased in 2 horses. PI scores were improved in 18 RLN horses and in 6 horses without RLN; there was no statistical difference in outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

Use of RLN in combination with laryngoplasty and ventriculocordectomy for treatment of grade III LLH may not improve postoperative racing performance.

Career racing performance in Thoroughbreds treated with prosthetic laryngoplasty for laryngeal neuropathy: 52 cases (1981-1989)

OBJECTIVE

To compare racing performance before and after prosthetic laryngoplasty for treatment of laryngeal neuropathy in inexperienced and experienced Thoroughbred racehorses.

DESIGN

Retrospective study.

ANIMALS

52 Thoroughbred racehorses treated with prosthetic laryngoplasty for laryngeal neuropathy.

PROCEDURE

Lifetime race records were analyzed by use of a verified regression model. Individual race records and hospital records were also reviewed.

RESULTS

Experienced horses had a decline in performance, as measured by performance index, earnings percentage, and mean prediction error, during the 6-month period before prosthetic laryngoplasty. Performance improved after surgery, relative to performance in 1 to 4 races immediately before surgery, but did not attain previous baseline values for performance index and earnings percentage, although racing speed was restored to baseline values. Factors associated with failure to attain baseline levels of performance included other racing-related injuries and disorders, major complications of surgery, and age. Individually, however, many horses had long and successful careers after surgery. Performance of inexperienced horses after surgery was at least equal to that of experienced horses.

CONCLUSIONS AND CLINICAL RELEVANCE

In addition to warning clients of the complications associated with prosthetic laryngoplasty, it may be prudent to provide a guarded prognosis for full restoration of racing performance in older horses, unless they are especially talented and are free of other racing-related problems.

An in vitro comparison of cordopexy, cordopexy and laryngoplasty, and laryngoplasty for treatment of equine laryngeal hemiplegia

OBJECTIVE

To examine the effect of cordopexy, laryngoplasty, and cordopexy combined with a modified laryngoplasty on airway mechanics.

STUDY DESIGN

Experimental airway mechanics were determined by subjecting equine cadaveric larynges to airflows similar to inspiratory airflow of exercising horses.

ANIMALS OR SAMPLE POPULATION

Twenty equine larynges.

METHODS

Using cadaveric larynges, we developed and tested a new technique of arytenoid cartilage abduction. All larynges had the right arytenoid cartilage abducted to mimic the degree of arytenoid abduction that occurs at maximal exertion in live horses. Three surgical techniques were used to stabilize the left arytenoid cartilage of treated larynges; the left arytenoid cartilage was not stabilized in control larynges. Technique 1: Cordopexy--a suture was placed between the vocal ligament and the lamina of the thyroid cartilage. Technique 2: Standard laryngoplasty--a suture was placed between the muscular process of the arytenoid cartilage and the caudomedial aspect of the cricoid cartilage. Technique 3: Cordopexy plus modified laryngoplasty--the cordopexy suture was placed with a second suture between the horizontal ridge rostral to the muscular process of the left arytenoid cartilage and the lamina of the thyroid cartilage. Translaryngeal impedances (TI) were determined for each surgical technique by subjecting the larynges to increasing airflows and measuring the translaryngeal pressure differences. The arytenoid right to left angle quotient (RLQ) and the glottic cross-sectional area (CSA) were also measured.

RESULTS

At maximal airflow, the adjusted means for the arytenoid RLQ and the TI for the cordopexy plus modified laryngoplasty (1.48 +/- 0.04, 0.69 +/- 0.05 cm H2O/L/s) and the standard laryngoplasty (1.39 +/- 0.04, 0.78 cm H2O/L/s) were different (P < .05) from values obtained after cordopexy alone (2.74 +/- 0.37, 1.76 +/- 0.48 cm H2O/L/s) or in control larynges (3.66 +/- 0.54, 4.16 +/- 0.96 cm H2O/L/s). Overall, a cordopexy plus modified laryngoplasty (9.69 cm2), a standard laryngoplasty (9.34 cm2), and a cordopexy alone (9 cm2) resulted in an increased glottic CSA greater than that for control larynges (6.94 cm2; P = .0001).

CONCLUSIONS

Cordopexy alone did not improve airflow in a left laryngeal hemiplegic model. Cordopexy plus modified laryngoplasty was as efficacious as the standard laryngoplasty in alleviating the effects of left laryngeal hemiplegia on TI, glottic CSA, and arytenoid RLQ.

CLINICAL RELEVANCE

Fixation of the vocal cord (cordopexy) in addition to a laryngoplasty procedure may prove useful in the surgical treatment of equine laryngeal hemiplegia.

In vitro evaluation of a novel prosthesis for laryngoplasty of horses with recurrent laryngeal neuropathy

A prosthesis, composed of a steel cable and stress-reducing washers, was developed to prevent failure of laryngoplasty, a common treatment for horses affected by recurrent laryngeal neuropathy. Laryngoplasties were performed on 15 cadaveric larynges using a polyester suture on one side and the cable prosthesis on the other. Each prosthesis was distracted at a displacement rate of 20 mm/s using a servohydraulic materials testing machine until laryngoplasty failed. Distraction force and actuator displacement were recorded and analysed. All 15 laryngoplasties performed with a suture failed at the muscular process at a mean +/- s.d. force of 55.8 +/- 13.1 N. Six laryngoplasties performed with the cable prosthesis failed at the muscular process at mean force 219.6 +/- 125.0 N. In the other 9, the arytenoid cartilage was avulsed from the larynx at mean force 206.4 +/- 75.3 N, and the cable then tore through the muscular process at mean force 357.0 +/- 32.0 N. The difference in force required to cause failure of laryngoplasty was significant (P<0.0001). Although the prosthesis resisted substantially higher forces than did the suture, the effects of the prosthesis in vivo must be evaluated.

Pulmonary capillary pressure in horses undergoing alteration of pleural pressure by imposition of various upper airway resistive loads

We hypothesized that changes in pleural pressure induced by resistive breathing would affect transmural pulmonary artery, pulmonary capillary, and pulmonary wedge pressures. Seven horses were assigned to exercise with each of 4 upper respiratory resistive loads in random order at intervals of at least 2 days: 1) control--no added resistive loads; 2) inspiratory resistive load (Iobst)--left laryngeal hemiplegia; 3) expiratory resistive load (Eobst)--one-way valve in the right nostril; and 4) combined inspiratory and expiratory resistive loads (CIEobst)--left nostril occlusion. On each occasion, the horses performed an incremental exercise protocol consisting of exercise episodes of 3 min duration at 75, 90, and 100% of maximal heart rate (HRmax). Pulmonary artery and oesophageal pressures were recorded continuously. Subsequent analysis was carried out on the pulmonary arterial pressure signal with the oesophageal pressure signal subtracted, hence the pulmonary vascular pressures in this paper approximate transmural pressures. Pulmonary vascular pressures, heart rate, and arterial blood gas tensions were measured at each level of exercise. Pulmonary capillary and pulmonary wedge pressures were determined from the pulmonary artery waveform after dynamic occlusion of a branch of the pulmonary artery. During exercise, peak expiratory oesophageal pressure was more positive in horses with Eobst and CIEobst (adjusted means = 43, and 39 mmHg, respectively) compared with control (adjusted mean = 23 mmHg) (P = 0.0001). Peak inspiratory oesophageal pressure was more negative in horses at exercise with Iobst and CIEobst (adjusted means = -42 and -39 mmHg, respectively) compared with control (adjusted mean = -26 mmHg) (P = 0.0012). Eobst was associated with an increase in mean oesophageal pressure while Iobst was associated with a decrease in mean oesophageal pressure. There were significant increases in mean pulmonary artery pressure in horses with CIEobst (adjusted means = 82 mmHg) and in pulmonary wedge pressure in horses with CIEobst and Iobst (adjusted means = 51, and 55 mmHg, respectively) when compared to control (73 and 42 mmHg, respectively) (P = 0.0001). Pulmonary capillary pressure was significantly increased in horses with CIEobst or Iobst (adjusted means = 61 mmHg, 63 mmHg, respectively) when compared to control (adjusted mean = 50 mmHg)(P = 0.0001). At maximal exercise intensity with inspiratory obstruction, the mean oesophageal (pleural) pressure was -17 mmHg while the mean pulmonary capillary pressure was 77 mmHg. The latter exceeds the reported 75 mmHg threshold for capillary failure in horses. We conclude that inspiratory resistive breathing can lead to a significant increase in transmural pulmonary capillary pressure which may contribute to loss of capillary integrity and rupture.

Airflow mechanics in models of equine obstructive airway disease under conditions simulating exercise

Effects of respiratory tract obstructions on ventilatory mechanics in horses exercising at high speeds were tested with a fibreglass replica of the airways (nares to mainstem bronchi) of an adult horse. Segmental pressures were recorded at six sites along the model at four different unidirectional flows (1300-4100 litre min-1), and the respective resistances (R) to airflow were calculated. The external nares and the larynx made the greatest contributions to the total resistance (RTOT) when no obstruction was present. Modifying the model to simulate severe pharyngeal lymphoid hyperplasia (PLH) had no effect on R at the larynx or at any point in the trachea under these flow conditions. Two 16 litre anaesthetic rebreathing bags were attached to the bronchial end of the model, and tidal ventilation generated by a piston pump. Upper (nares to pharynx) and lower tract R (RU and RL) and RTOT, and dynamic compliance were determined for pump volumes (Vp) of six and 12 litres, at pumping frequencies (fp) of 20-100 min-1 while the airway was clear, and after modifying it to simulate either PLH or partial bronchial obstruction. Model condition had no effect on RU. However, RL and RTOT were higher in the PLH simulated condition when fp > or = 90 and Vp = 12 litres (P < 0.05). This suggested that severe PLH may significantly interfere with airflow distal to the site of the lesions during high frequency high volume ventilation of the type seen in galloping horses. With partial bronchial obstruction RL and RTOT were increased when fp > 34 with each Vp. The applicability of the model was verified by comparing results from the unobstructed state with those from normal horses exercising on a treadmill.

Cardiorespiratory responses to exercise in horses with different grades of idiopathic laryngeal hemiplegia

The relationship between different grades of laryngeal function, as assessed by endoscopy at rest, and the measurements of indices of gas exchange and exercise capacity was assessed during a standardised treadmill exercise test in 149 horses. Horses with abnormalities other than idiopathic laryngeal hemiplegia (ILH) were excluded from the study and laryngeal function was graded according to an established system. There were no significant differences in age, weight, maximum oxygen uptake, maximum carbon dioxide production, maximum respiratory exchange ratio, maximum oxygen pulse and run time between the grades. Blood lactate concentration at 10 m/s was greater (P < 0.01) in horses with grade 5 laryngeal function than other grades. Minimum PaO2 (P < 0.001) and SaO2 (P < 0.01) were lower and maximum PaCO2 (P < 0.001), higher in horses with grades 4 and 5 laryngeal function than other grades. Horses with grade 4 function had a lower minimum CaO2 (P < 0.01) than horses with other grades. Minimum PAO2 decreased from grades 1 and 2 to grades 4 and 5 (P < 0.05). The minimum alveolar ventilation was lower (P < 0.05) in horses with grades 4 and 5 laryngeal function compared to other grades. The results of this study indicate that endoscopic assessment of laryngeal function at rest, using a simple grading system, provides an indication of dynamic changes in ventilation and the effects on blood gases during exercise. From the data, we suggest that horses that have some movement of the left arytenoid cartilage but are unable to achieve full abduction have similar ventilatory effects and blood gas responses during maximal exercise to those with complete paralysis. Some horses with grade 3 laryngeal function had blood gas results similar to those of horses with grades 4 and 5 laryngeal function, indicating that discrepancies may occur between the resting assessment and laryngeal function during strenuous exercise.

Instrumentation and techniques in respiratory surgery

In this article, videoendoscopy in conjunction with high-speed treadmill exercise and other specialized diagnostic techniques used to measure upper airway function are reviewed as they pertain to the four most commonly diagnosed functional upper airway obstructions: (1) laryngeal hemiplegia, (2) arytenoid chondritis, (3) epiglottic entrapment, and (4) intermittent dorsal displacement of the soft palate. Using experimental and clinical findings obtained with these new instruments and diagnostic techniques, current recommendations for surgery of these obstructions are presented.

Cardiorespiratory and metabolic responses to exercise in horses with various abnormalities of the upper respiratory tract

A standardised incremental exercise test was performed by 9 racehorses with idiopathic laryngeal hemiplegia (ILH), 1 horse with maxillary sinus cysts, 1 horse with epiglottic entrapment, 1 horse with a lesion on the vocal folds, and 1 horse with pharyngitis. Two of the horses with ILH were retested after laryngoplasty and ventriculectomy. The findings were compared with those from 20 normal racehorses. Heart rate, plasma lactate concentration, arterial blood gases, stride frequency, oxygen uptake (VO2) and carbon dioxide production were assessed during treadmill exercise on a +10% slope. The group of horses with ILH had significantly (P < 0.01) lower peak VO2 values (136 +/- 5 ml/kg/min) than did the normal group (154 +/- 3 ml/klg/min). These values represent mean +/- sem. Horses with ILH also had significantly higher (P < 0.05) arterial carbon dioxide tensions (PaCO2) at 10 m/s and lower speeds at a heart rate of 200 bpm (V200) than the normal group. The horse with maxillary sinus cysts had higher PaCO2 tension at 10 m/s than normal, and abnormal values for several cardiorespiratory and metabolic indices. Horses with vocal fold lesions, aryepiglottic entrapment and pharyngitis had arterial blood gas and cardiorespiratory indices that were similar to those of normal horses. One horse which underwent corrective surgery for ILH showed improvements in arterial blood gases and cardiorespiratory indices during exercise, while the other horse had values which were the same as, or worse than, values before surgery. We conclude that the measurement of arterial blood gases and cardiorespiratory indices during treadmill exercise is useful in determining the effect on exercise capacity of various upper airway abnormalities in racehorses.

Additional diagnostic procedures

This article reviews recent diagnostic procedures that have arisen over the last 10 years. Videoendoscopy of horses on a high-speed treadmill allows observation of some of the changes that take place in a horse's airway during exercise. Measurements of upper airway airflows and transupper airway pressure, the use of an esophageal balloon and a Ventigraph to measure changes in pleural pressure, and pulmonary function testing are new techniques that aid the researcher in understanding the mechanics and pathologic characteristics of airway diseases and help the practitioner in assessing the severity of a problem, measuring response to therapy, and accurately determining a prognosis.