ILMU BEDAH KHUSUS VETERINER

TEKNIK OPERASI LARYNGOTOMY

DISUSUN OLEH:
Varhan Dwiyan Indra 1809511044
Ferdy Olga Saputra 1809511050
Maharani Lisna Wulandari 1809511056
Kelas B

FAKULTAS KEDOKTERAN HEWAN

UNIVERSITAS UDAYANA
DENPASAR
2021
 KATA PENGANTAR
Puji syukur kami panjatkan atas kehadiran Tuhan Yang Maha Esa karena
atas berkat dan rahmat-Nya kami dapat menyelesaikan tugas mata kuliah Ilmu
Bedah Khusus Veteriner yang berjudul “Teknik Operasi Laryngotomy” dengan
sebagaimana mestinya.

Penulisan tugas yang berjudul “Teknik Operasi Laryngotomy” ini bertujuan

untuk memenuhi tugas mata kuliah Ilmu Bedah Khusus Veteriner yang diberikan.
Selain itu, penulisan tugas ini juga bertujuan untuk menambah wawasan dan
pengetahuan pembacanya. Segala kritik dan saran sangat penulis harapkan demi
kebaikan dari tulisan ini, dan tak lupa penulis ucapkan banyak terima kasih.

Denpasar, 11 Oktober 2021

Hormat kami,

Penulis

ii
 DAFTAR ISI

KATA PENGANTAR ........................................................................................... ii

DAFTAR ISI ......................................................................................................... iii
DAFTAR GAMBAR ............................................................................................ iv
BAB I PENDAHULUAN ...................................................................................... 1
1.1 Latar Belakang............................................................................................... 1
1.2 Rumusan Masalah ......................................................................................... 1
1.3 Tujuan ............................................................................................................ 1
1.4 Manfaat .......................................................................................................... 2
BAB II TINJAUAN PUSTAKA ........................................................................... 3
2.1 Terminologi ................................................................................................... 3
2.2 Indikasi .......................................................................................................... 3
2.3 Anestesi ......................................................................................................... 5
2.4 Preoperasi ...................................................................................................... 6
2.5 Operasi........................................................................................................... 7
2.6 Pascaoperasi .................................................................................................. 9
BAB III PENUTUP ............................................................................................. 10
3.1 Kesimpulan .................................................................................................. 10
3.2 Saran ............................................................................................................ 10
DAFTAR PUSTAKA .......................................................................................... 11

iii
 DAFTAR GAMBAR
Gambar 1. Penampakan normal ring ....................................................................... 3
Gambar 2. Proses laryngotomi pada sapi ................................................................ 9

iv
 BAB I
PENDAHULUAN
1.1 Latar Belakang
Laring merupakan saluran pernapasan bagian atas dan merupakan pangkal
tenggorokan yang terdiri atas kepingan tulang rawan dan terdapat celah menuju
batang tenggorokan (trakea) yang disebut glotis. Fungsi laring untuk
mengontrol ekspirasi dan inspirasi, mencegah inhalasi benda-benda asing dan
bersifat esensial untuk pembentukan bunyi. Terjadinya abnormalitas dapat
menyebabkan tejadinya gangguan fungsi laring. Beberapa abnormalitas yang
dapat terjadi pada laring antara lain obstruksi laring yang dapat disebabkan
akibat radang akut dan radang kronis, benda asing, trauma akibat kecelakaan,
perkelahian, trauma Akibat tindakan medis, tumor laring, baik berupa tumor
jinak atau pun tumor ganas.
Laryngotomy merupakan tindakan operasi yang dilakukan dengan cara
membuka dan memotong ke dalam laring dengan menggunakan peralatan
khusus. Laringotomi dapat dilakukan melalui pendekatan ventral laryngotomy
dan lateralisasi kartilago aritenoid. Hal ini umum dilakukan pada ternak/hewan
peliharaan yang mengalami gangguan pernafasan dan berbagai abnormalitas.
1.2 Rumusan Masalah
1. Apa yang dimaksud dengan laryngotomy?
2. Apa saja indikasi laryngotomy?
3. Bagaimana anestesi laryngotomy?
4. Bagamana tindakan praoperasi laryngotomy?
5. Bagaimana teknik operasi laryngotomy?
6. Bagaimana tindakan pascaoperasi laryngotomy?
1.3 Tujuan
1. Untuk mengetahui apa yang dimaksud dengan laryngotomy.
2. Untuk mengetahui indikasi laryngotomy.
3. Untuk mengetahui bagaimana anestesi laryngotomy.
4. Untuk mengetahui bagamana tindakan praoperasi laryngotomy.
5. Untuk mengetahui bagaimana teknik operasi laryngotomy.
6. Untuk mengetahui bagaimana tindakan pascaoperasi laryngotomy.

1
1.4 Manfaat
Manfaat dari penulisan paper ini adalah dapat bermanfaat bagi pembaca
khususnya mahasiswa Fakultas Kedokteran Hewan dan dapat memahami
mengenai Teknik operasi Laryngotomy dan indikasi penggunaanya. Selain itu
diharapkan mampu menjadi referensi untuk penulisan selanjutnya.

2
 BAB II
TINJAUAN PUSTAKA
2.1 Terminologi
Operasi laryngotomy adalah operasi pada laring dengan cara menginsisi
dinding laring menggunakan laryngotome. Laryngotomy dilakukan ketika
saluran respirasi hewan bagian atas telah mengalami gangguan seperti
terhalang benda asing atau adanya obstruksi sehingga hewan tersebut menjadi
sulit bernafas. Operasi laryngotomy dapat bersifat permanen atau sementara
untuk membantu aliran nafas.

Gambar 1. Penampakan normal ring

2.2 Indikasi
Indikasi dilakukannya operasi laryngotomy adalah adanya oedema dan
peradangan pada laryng, adanya infeksi, adanya benda asing, obstruksi laring,
collaps laring, gangguan pada katup epligotis yang dapat ditandai dengan
hewan yang sering batuk, tersedak, atau kesulitan bernafas, penyayatan parsial
pada langit-langit lunak, arytenoidectomy, faring limfoid hiperplasia, orsal
displacemnet langit-langit lunak, laryngeal ventriculocordectomy,
pengangkatan kantung laring, debarking, laryngotomi parsial, dan trakeotomi
sementara untuk melindungi jalan nafas selama penyembuhan. Kelebihan
operasi laryngotomy adalah operasi pada kuda dapat dilakukan dengan posisi
berdiri sehingga operasi dapat mudah dilakukan dan resiko komplikasi minim.
Sementara kekurangan operasi laryngotomy adalah membutuhkan endotrakeal
tube atau intubasi trakea via tracheotomy serta terbatasnya akses terhadap
faring dan laring kranial.

3
Beberapa macam operasi laryngotomy meliputi:
a. Laringektomi parsial (laringotomi–tirotomi)
Laringektomi parsial direkomendasikan pada kanker area glotis
tahap dini ketika hanya satu pita suara yang kena. Tindakan ini
mempunyai angka penyembuhan yang sangat tinggi. Dalam operasi
ini, satu pita suara diangkat dan semua struktur lainnya teteap utuh.
Suara pasien kemungkinan menjadi parau, jalan nafas akan tetap
utuh dan pasien seharusnya tidak memiliki kesulitan menelan.
b. Laringektomi supraglotis (Horizontal)
Laringektomi supraglotis digunakan dalam penatalaksanaan
tumor supraglotis. Tulang hyoid, glottis dan pita suara palsu
diangkat. Pita suara kartilogi krikoid dan trakea tetap utuh. Selama
operasi dilakukan di seksi leher radikal pada tempat yang sakit.
Selang traketomi dipasang dalam trakea sampai jalan nafas glottis
pulih. Selang traketomi diangkat beberapa hari setelahnya dan
biarkan stoma menutup dengan sendirinya. Selama masa itu, untuk
nutrisi hewan, selang nasograstik diberikan sampai terdapat
penyembuhan dan tidak ada lagi resiko aspirasi. Pasca operatif, klien
kemungkinan akan mengalami kesulitan untuk menelan selama 2
minggu pertama. Keuntungan utama dari operasi ini adalah bahwa
suara akan kembali pulih seperti biasa.
c. Laringektomi Hemivertikal
Dilakukan jika tumor meluas di luar pita suara, tetapi perluasan
tersebut kurang dari 1 cm dan terbatas pada area subglotis. Dalam
prosedur ini, kartilago tiroid laring dipisahkan dalam garis tengah
leher dan bagian pita suara (satu pita suara sejati dan satu pita suara
palsu) dengan pertumbuhan tumor diangkat. Kartilago aritenoid dan
setengah kartilago tiroid diangkat. Pasien akan mempunyai selang
trakeostomi dan selang nasogastrik selama operasi. Pasien beresiko
mengalami operasi pasca operatif. Beberapa perubahan dapat terjadi
pada kualitas suara (sakit tenggorokan) dan proyeksi. Namun
demikian fungsi nafas dan jalan menelan tetap utuh.

4
 d. Langektomi Total
Prosedur ini diaplikasikan ketika kanker meluas hingga daerah
luar pita suara, seperti daerah tulang hyoid, daerah epiglottis, daerah
kartilago krikoid, dan dua atau tiga cincin trakea. Dalam keadaan
tertentu, daerah ini akan diangkat secara bersamaan. Sedangkan
lidah, dinding faringeal, dan trakea akan tetap dibiarkan pada
tempatnya. Laringektomi total membutuhkan stoma trakeal
permanen. Stoma ini mencegah aspirasi makanan dan cairan ke
dalam saluran pernapasan bawah, karena laring yang memberikan
perlindungan spingter tidak ada lagi. Pasien tidak akan mempunyai
suara lagi tetapi fungsi menelan akan normal. Laringektomi total
merubah cara dimana aliran udara digunakan untuk bernafas dan
berbicara.
2.3 Anestesi
a) Pada sapi
Sapi disedasi dengan xylazine HCL 0,1-0,2 mg/kg BB secara
intramusculer dan anestesi infiltrasi lokal pada area laring (Lidocaine 2 per
centi) atau Lignocaine 15-25 ml per 2 centi subcutan. Dapat juga dengan
anestesi umum, anestesi inhalasi dengan Halotan dengan posisi dorsal
recumbency.
b) Pada kuda
Laringotomy dilakukan pada kuda dengan anestesi umum Pertama kuda
diberikan premedikasi dengan dosis 0,1mg/kg midazolam secara intravena
dan kemudian anestesi diinduksi dengan menggunakan 2,2 mg/kg ketamin
hidroklorida secara intravena. Kemudian anestesi dimaintain dengan
pemberian halotan di dalam oksigen dan diberikan secara inhalasi. dan
hewan dibaringkan secara dorsal recumbency. Dapat juga dilakukan dalam
keadaan hewan tersedasi berdiri (standing sedated) dengan anestesi lokal
pada daerah pengoperasian dengan menggunakan phenylbutazone 3-6
mg/kg BB secara intravena.

5
 c) Anjing dan kucing
Dengan menggunakan thiopental secara intra vena 13,2-26,4 mg/kg
BB. Pramedikasi dengan Acepromazine secara intramuskuler 0.01-0.05
mg/kg BB, kemudian induksi dengan butorphanol 0.05 mg kg/BB secara
Intra vena, dikuti dengan pemeliharaan dengan isofluran secara inhalasi
(1,5-2%). Penggunaan anestesi diatas memilki keunggulan tidak
mengakibatkan pergerakan pada laring. Ada beberapa pilihan anestesi lain
yaitu propofol secara intavena, Ketamine ditambah diazepam secara
intravena, acepromazine secara i.M ditambah thiopental seara i.V atau
Acepromazien secara i.M ditambah propofol secara i.V. namun penggunaan
obat ini dapat mengakibatkan efek pada laring sehingga dapat mengganggu
proses pembedahan. Pada kucing cukup dengan menggunakan Ketamin dan
Xylasin dengan pemberian Atropin sebelumnya, dosis anastesi disesuaikan
dengan jenis hewan, berat badan, sediaan obat anastesi.
2.4 Preoperasi
Sebelum melakukan tindakan operasi terlebih dahulu dilakukan persiapan
operasi. Adapun persiapan yang dilakukan adalah persiapan alat atau
instrument bedah, persiapan ruangan operasi, persiapan pasien, dan persiapan
operator.
• Persiapan Alat atau Instrumen Bedah.
Alat dan instrument bedah sebaiknya dipersiapkan segera sebelum
operasi, yaitu dengan cara mencuci alat menggunakan sabun, dibilas
menggunakan air hangat, menggunakan desinfektan, dikeringkan dan
dimasukkan ke dalam autoclave.
• Persiapan Ruang Operasi.
Ruang operasi dibersihkan menggunakan desinfektan. Sedangkan meja
operasi didesinfeksi dengan menggunakan alkohol 70%. Penerangan ruang
operasi sangat penting untuk menunjang operasi, oleh karena itu sebelum
diadakanya operasi persiapan lampu operasi harus mendapatkan
penerangan yang cukup agar daerah/site operasi dapat terlihat jelas.

6
 • Persiapan Pasien (hewan).
- Pemeriksaan Fisik: Hewan harus dievaluasi secara sistematis sepanjang
pemeriksaan fisik, dan semua sistem badan hewan harus diperiksa.
Kondisi umum (kondisi badan, sikap, dan status mental) harus dicatat.
- Urinasi dan defekasi: Untuk mencegah kontaminasi dari feses hewan
atau urin, hewan dipuasakan sekurang-kurangnya 12 jam dan dilakukan
pengosongan vesica urinaria lewat kateter.
- Pemotongan Rambut: Untuk mencegah kontaminasi yang terjadi
sebelum, atau saat pembedahan berlangsung seminimal mungkin, dapat
dilakukan pemotongan rambut dengan cara memotong rambut pada
daerah pembedahan dengana area yang luas, umumnya dengan garis
tengah 15 cm.
• Persiapan Operator (petugas yang akan melakukan operasi).
Operator dan tim pembedahan yang terdiri dari dokter hewan harus siap
seara fisik dan mental, memahami prosedur operasi, dan terampil, serta
harus menjaga higiene agar tidak terjadi kontaminasi, seperti menggunakan
alas kaki, masker, penutup kepala, baju operasi, sarung tangan, dll.
2.5 Operasi
• Pendekatan Ventral Laryngotomy
Pendekatan ini memberikan pembukaan yang lebih baik untuk prosedur
pada anjing kecil.
− Hewan diposisikan pada dorsal recumbency, dan diposisikan dengan
baik ke meja operasi.
− Sayatan kulit bagian ventral dibuat pada laring melalui midline. Otot
sternohyoideus dipisahkan dan ditarik ke lateral dengan retraktor Gelpi.
Membran krikotiroid dan tulang rawan tiroid di insisi pada garis tengah,
dan ujung-ujungnya ditarik dengan forceps Gelpi kecil untuk
mengekspos tulang rawan arytenoid dan vocal fold.
− Setelah itu lakukan insisi pada mukosa corniculate, cuneiform, dan
proses vokal dari satu arytenoid tulang rawan. Setiap mukosa
berlebihan yang dipotong, dan mukosa dijahit untuk mengurangi
produksi jaringan granulasi dan meningkatkan ukuran jalan udara.

7
 − Penutupan mukosa yang dilakukan menggunakan benang absorbable
(5-0 atau 6-0) dengan pola menerus. Sayatan kartilago tiroid dijahit
dengan benang non absorbable dan pola terputus yang tidak menembus
lumen laring untuk mencegah utama dari tepi tulang rawan. Jaringan
subkutan di tutup dengan jahitan continuous dan kulit ditutup dengan
jahitan simple interrupted.
− Bersihkan dengan antiseptic dengan alcohol. Berikan antibiotic local
dan sistemik pada akhir operasi.
• Laseralisasi Cartilage Arytenoid
− Hewan diberikan anastesi umum
− Hewan tersebut diposisikan dalam posisi lateral recumbency untuk
melakukan lateralisasi unilateral, dan sayatan kulit dibuat sepanjang
ventral alur jugularis laring.
− Otot sternohyoid ditarik kembali bagian ventral untuk mengekspos
aspek lateral tiroid dan tulang rawan krikoid.
− Laring diputar untuk mengekspos otot thyropharyngeal, yang
ditranseksi pada tepi dorsocaudal dari tulang rawan tiroid.
− Sayap (alae) tulang rawan tiroid ditarik ke lateral, dan persimpangan
krikotiroid (krikotiroid junction) dilakukan penorehan. Sayatan dari
sendi krikotiroid memberikan eksposur yang lebih baik, tetapi tidak
selalu dilakukan. Transeksi mungkin mengurangi diameter dari
glottidis rima setelah penarikan arytenoid.
− Otot cricoarytenoideus dorsalis atau bagian kiri dari jaringan fibrosa
dilakukan incisi dan transeksi.
− Artikulasi Cricoarytenoid dipotong dari kaudal ke kranial dengan
menggunakan gunting Metzenbaum.
− Tulang rawan arytenoid dijahit ke bagian caudo-dorsal kartilago krikoid
dengan benang nonabsorbable dengan pola jahitan terputus sederhana.
Dalam pemilihan bahan benang untuk penjahitan, tidak boleh terlalu
besar agar tidak menganggu saluran pernafasan (contoh pada kucing
menggunakan ukuran benang nonabsorbable 3-0 atau 4-0) tulang rawan

8
 arytenoid hanya perlu dipertahankan dalam posisi dan stabil pada
inspirasi.
− Luka ditutup dengan menjahit otot thyropharyngeal dengan pola
terputus menggunakan benang absorable (cat gut 2 -0)
− Dilanjutkan penjahitan dengan pola simple kontinue untuk menutup
jaringan subkutan menggunakan benang absorable (cat gut 2 -0)
− Kulit dijahit dengan pola terputus menggunakan benang nonabsorbable
− Bekas jahitan / daerah incisi diberikan providone iodin 10% dan dibalut
dengan perban.

Gambar 2. Proses laryngotomi pada sapi

2.6 Pascaoperasi
Pascaoperasi meliputi pengobatan, perawatan, dan observasi. Setelah
recovery, daerah di insisi harus dibersihkan dengan larutan encer dari
povidone-iodine atau chlorhexidine dan dibalut dengan perban. Penggunaan
selang untuk alat bantu pernafasan juga dilakukan beberapa jam pasca operasi
sehingga pemberian oksigen bisa langsung menuju ke trachea.
Hewan diberi makan secara parenteral dengan infus selama masa
perawatan. Bekas incisi dari Laryngotomy dibersihkan 2 kali sehari selama 14
hari. Jahitan diambil setelah 12-14 hari. Aplikasi Fenylbutason diberikan
selama 3-5 hari setiap 24 jam. Gejala gangguan pernafasan serta gangguan
organ vital lain juga diamati. Lakukan juga pemberian antibiotik untuk
mencegah infeksi.
Antiinflamasi diberikan guna mencegah peradangan pada saluran
pernafasan. Luka operasi akan sembuh sekitar 1-2 minggu. Dan hewan dapat
diberikan latihan maupun pekerjaan setelah 2 minggu. Hindari lokasi berdebu
terutama saat masa penyembuhan.

9
 BAB III
PENUTUP
3.1 Kesimpulan
Operasi laryngotomy adalah operasi pada laring dengan cara menginsisi
dinding laring menggunakan laryngotome. Indikasi dilakukannya operasi
laryngotomy adalah adanya oedema dan peradangan pada laryng, adanya
infeksi, adanya benda asing, obstruksi laring, collaps laring, gangguan pada
katup epligotis yang dapat ditandai dengan hewan yang sering batuk, tersedak,
atau kesulitan bernafas, penyayatan parsial pada langit-langit lunak,
arytenoidectomy, faring limfoid hiperplasia, dorsal displacemnet langit-langit
lunak, laryngeal ventriculocordectomy, pengangkatan kantung laring,
debarking, laryngotomi parsial, dan trakeotomi sementara untuk melindungi
jalan nafas selama penyembuhan.

Operasi laryngotomy menggunakan pendekatan ventral laryngotomy dan

laseralisasi cartilage arytenoid. Pascaoperasi meliputi pengobatan, perawatan,
dan observasi.

3.2 Saran
Koreksilah paper ini, jika terdapat kesalahan kata dan kalimat yang
disengaja maupun tidak sengaja serta kesalahan kami dalam pemahaman
materi. Jika ada yang tidak dimengerti dari paper ini, penulis menyarankan
untuk membaca teksbook dan jurnal mengenai laryngotomy.

10
 DAFTAR PUSTAKA
Barroso, Jose Manuel. (2013). List of substances essential for the treatment of
equidae and substances bringing added clinical benefit compared to other
treatment options available for equidae. Official Journal of The European
Union. 42: 1-17.
Curella, Patricia et al. (2009). Canine Devocalization. Save The Voice.
Griffin, John F et al. (2005). Laryngeal Paralysis: Pathophysiology, Diagnosis, and
Surgical Repair. Article Of Tennessee University. 4: 857-869.
Kitshof, Adriaan M., Bart Van Goethem, Ludo Stegen, Peter Vandekerckhove dan
Hilde de Rooster. 2013. Laryngeal paralysis in dogs: An update on recent
Knowledge. Department of Small Animal Medicine and Clinical Biology.
University of Ghent. Belgium. Journal of the South African Veterinary
Association 84(1), Art. #909, 9 pages.

Millard, P. Ralph dan Karen M. Tobias. 2009. Laryngeal paralysis in dogs.

Compendium: continuing education for veterinarians

11

Laryngeal paralysis in dogs: An update on recent
knowledge
Authors:
Adriaan M. Kitshoff1
Bart Van Goethem1
Ludo Stegen1
Peter Vandekerckhove2
Hilde de Rooster1
Affiliations:
1
Department of Small
Animal Medicine and Clinical
Biology, University of Ghent,
Belgium
Veterinary Centre
2 guarded prognosis. Acquired idiopathic LP is a slow progressive disease, with dogs reaching
Malpertuus, Heusden,
Ghent, Belgium
Correspondence to:
Adriaan Kitshoff
Email:
adriaan.kitshoff@ugent.be
Postal address:
133 Salisbury Avenue,
Merelbeke, Ghent 9820,
Belgium
Dates:
Received: 24 July 2012
Accepted: 18 Dec. 2012
Published: 05 Apr. 2013
How to cite this article:
Kitshoff, A.M., Van
Goethem, B., Stegen, L.,
Vandekerckhove, P. & De
Rooster, H., 2013, ‘Laryngeal
paralysis in dogs: An update
on recent knowledge’,
Journal of the South African
Veterinary Association 84(1),
Art. #909, 9 pages.
http://dx.doi.org/10.4102/
jsava.v84i1.909
Copyright:
© 2013. The Authors.
Licensee: AOSIS
OpenJournals. This work
is licensed under the
Creative Commons
Attribution License.
Read online:
Scan this QR
code with your
smart phone or
mobile device
to read online.
Page 1 of 9 Review Article
Laryngeal paralysis is the effect of an inability to abduct the arytenoid cartilages during
inspiration, resulting in respiratory signs consistent with partial airway obstruction. The
aetiology of the disease can be congenital (hereditary laryngeal paralysis or congenital
polyneuropathy), or acquired (trauma, neoplasia, polyneuropathy, endocrinopathy). The
most common form of acquired laryngeal paralysis (LP) is typically seen in old, large breed
dogs and is a clinical manifestation of a generalised peripheral polyneuropathy recently
referred to as geriatric onset laryngeal paralysis polyneuropathy. Diagnosing LP based on
clinical signs, breed and history has a very high sensitivity (90%) and can be confirmed by
laryngeal inspection. Prognosis after surgical correction depends on the aetiology: traumatic
cases have a good prognosis, whereas tumour-induced or polyneuropathy-induced LP has a
median survival times of 3–5 years after surgical correction.
Introduction
It is the authors’ opinion that the incidence of laryngeal paralysis (LP) is higher than commonly
perceived. This is mainly a result of incorrect diagnosis because of a failure to recognise the typical
clinical signs. The authors’ experience has shown that many cases that are correctly diagnosed
are given an improper grave prognosis. New findings regarding idiopathic LP make the disease
progression and response to therapy easier to comprehend (Stanley et al. 2010). Adaptations of
the surgical techniques and the use of the unilateral arytenoid lateralisation drastically decreased
the associated complications (MacPhail & Monnet 2001; White 1989).
The aim of this article is to sensitise the reader to the clinical signs and treatment options for LP.
An update will also be given on the laryngeal anatomy, aetiology and the diagnosis of LP in dogs.
The most commonly encountered complications are also discussed.
Anatomy
The larynx is a semi-rigid organ composed mainly of hyaline cartilage and muscles (Evans
1993). During inspiration, contraction of the cricoarytenoideus dorsalis (CAD) muscle results in
abduction of the arytenoid cartilages and vocal cords, opening up the glottic lumen and allowing
air to pass freely (Evans 1993). Failure of the CAD muscle to contract will result in narrowing of
the glottic lumen and respiratory stridor (Monnet & Tobias 2012).
The cartilages of the larynx include the epiglottic, arytenoid (paired), sesamoid, inter-arytenoid,
thyroid and cricoid cartilages (Figure 1). The arytenoid cartilages have the most complex
structure. Their irregular shape is the result of the corniculate, cuneiform, muscular and vocal
processes (Evans 1993). The muscular process is situated just lateral to the cricoarytenoid
articulation and acts as an insertion site for the CAD muscle (Evans 1993). The corniculate process
is the longer of the two dorsal processes and forms the dorsal margin of the laryngeal inlet. The
other dorsal process, the cuneiform process, is situated more rostroventrally than the corniculate
process (Evans 1993). The ventral part of this process lies in the aryepiglotic fold forming
most of the lateral boundary of the laryngeal inlet (Evans 1993). The ring shape of the cricoid
cartilage creates a rigid structure that supports the more elastic thyroid and arytenoid cartilages
(Monnet & Tobias 2012).
The thyropharyngeus (TP) muscle is situated on the dorsal and lateral aspect of the larynx
(Hermanson & Evans 1993). This muscle originates on the lateral aspect of the thyroid cartilage
and it extends dorsally to the pharynx to insert on the median plane (Hermanson & Evans 1993).
Contraction of this muscle, together with the cricothyroideus muscle, results in constriction of the
middle pharyngeal area that assists in swallowing and prevents air from entering the oesophagus
(Hermanson & Evans 1993). Opening of the glottis is caused by contraction of the CAD muscle
http://www.jsava.co.za doi:10.4102/jsava.v84i1.909
 Page 2 of 9
(Hermanson & Evans 1993). This muscle originates from the
dorsolateral surface of the cricoid cartilage and inserts on
the muscular process of the arytenoid cartilage (Hermanson
& Evans 1993). Contraction of the muscle results results
in caudodorsal displacement of the arytenoid cartilage
(abduction).
All the intrinsic muscles of the larynx, except the
cricothyroideus muscle, are innervated by the caudal
laryngeal nerve (terminal portion of the recurrent laryngeal
nerve) (Hermanson & Evans 1993). The left recurrent
laryngeal nerve (RLN) arches around the aorta and ascends
on the left side of the trachea, whereas the right RLN arches
around the right subclavian artery and ascends on the right
side of the trachea (Evans & Kitchell 1993). As the recurrent
laryngeal nerves ascend, they give rise to the paralaryngeal
recurrent nerves that run parallel to the RLN (Evans &
Kitchell 1993). The paralaryngeal recurrent nerves supply
sensory innervation to the oesophagus and the trachea
(Evans & Kitchell 1993).
Aetiologies and classification
Laryngeal paralysis can be congenital or acquired and,
depending on the aetiology, it occurs unilaterally or bilaterally
(Monnet & Tobias 2012; Stanley et al. 2010). A hereditary form
of LP has been described in Siberian huskies and bouviers
des Flandres (O’Brien & Hendriks 1986; Venker-van Haagen
1982). A loss of motor neurons in the nucleus ambiguus as
a result of an autosomal dominant trait, with secondary
Wallerian degeneration of the recurrent laryngeal nerves, has
been identified in the bouvier des Flandres (Parnell 2010).
This disease results in either unilateral or bilateral paralysis
and, generally, presents in dogs less than 12 months of age
(Burbidge 1995; O’Brien & Hendriks 1986; Ridyard et al. 2000;
Venker-van Haagen 1982).
Congenital LP polyneuropathy has been reported in
Rottweilers, bouviers des Flandres, bull terriers, Dalmatians,
German shepherd dogs, Afghan hounds, cocker spaniels,
a b
Source: Photographs by M. Doom
Evident in these views are the, (1) stylohyoid, (2) epihyoid, (3) ceratohyoid, (4) basihyoid (5) thyrohyoid, (6) epiglottis, (7a) corniculate process of the arytenoid cartilage, (7b) cuneiform process of
the arytenoid cartilage, (8) thyroid cartilage, (9) cricoid cartilage and (10) trachea.
FIGURE 1: Embalmed cadaver specimen of a canine larynx, depicted as, (a) rostrodorsal view with the muscles removed, (b) lateral view after removal of the muscles and
(c) rostrodorsal view with the dorsal aspect of the oesophagus removed.
http://www.jsava.co.za
Review Article
dachshunds, miniature pinchers and Siberian huskies
(Bennnett & Clarke 1997; Braund 1994; Braund et al. 1994;
Braund et al. 1989; Eger et al. 1998; Harvey & O’Brien 1982;
Mahony et al. 1998; O’Brien & Hendriks 1986; Ridyard et al.
2000; Venker-van Haagen 1982). Clinical signs indicating
the presence of a polyneuropathy can also be present. These
clinical signs include hyporeflexia (all four limbs), decreased
postural reactions, hypotonia and appendicular muscle
atrophy (Braund 1994; Braund et al. 1994; Davies & Irwin 2003;
Gabriel et al. 2006; Mahony et al. 1998; Ridyard et al. 2000).
In young Dalmatians and Rottweilers, axonal degeneration
together with loss of myelinated nerve fibres of the RLN
and paralaryngeal recurrent nerves are observed (Braund et
al. 1994; Braund et al. 1989; Mahony et al. 1998). Phenotypic
characteristics, such as white coat, freckles and blue eyes,
have been linked to LP in Siberian huskies and German
shepherd dogs (O’Brien & Hendriks 1986; Polizopoulou et al.
2003; Ridyard et al. 2000).
Acquired LP can be caused by trauma to the RLN or
vagus nerves in the cervical or thoracic region (e.g. bite
wounds, surgical trauma, mediastinal tumour) (Monnet
& Tobias 2012). Diseases such as neuropathies, caudal
brainstem disease, endocrine diseases (hypothyroidism and
hypoadrenocorticism), myasthenia gravis, paraneoplastoc
syndromes, idiopathic myositis, systemic lupus
erythematosus and organophosphate toxicity can also result
in LP (Burbidge 1995; Dewey et al. 1997; Kvitko-White et al.
2012; MacPhail & Monnet 2001; Michael 2002; Monnet &
Tobias 2012; White 1989). The term geriatric onset laryngeal
paralysis polyneuropathy (GOLPP) has recently been used to
described the commonly encountered syndrome of acquired
idiopathic laryngeal paralysis (AILP) (Monnet & Tobias
2012; Parnell 2010; Stanley et al. 2010). Strong evidence exists
that this form is a prominent clinical sign of a generalised
peripheral polyneuropathy (Jeffery et al. 2006; Stanley et
al. 2010). It commonly occurs in breeds such as Labrador
retrievers, Rottweilers, Afghan hounds, Irish setters, golden
retrievers, Saint Bernards, Irish setters and standard poodles
(Gaber, Amis & Le Couteur 1985; Monnet & Tobias 2012).
c
doi:10.4102/jsava.v84i1.909
 Page 3 of 9
In contrast to the congenital form, AILP is typically seen
in middle-aged to older large breed dogs (Burbidge 1995;
Parnell 2010). Male dogs are presented about twice as often
as females (Burbidge, Goulden & Jones 1991; MacPhail &
Monnet 2001; White 1989).
Clinical signs
Dogs with unilateral LP (mostly left-sided) will only display
clinical signs during strenuous activities (i.e. working dogs)
(Monnet & Tobias 2012). Failure to abduct the arytenoid
cartilages during inspiration results in increased resistance
to airflow and turbulence through the rima glottidis leads to
the typical inspiratory stridor (Stanley et al. 2010; Venker-van
Haagen 1982). Dysphonia is caused by the inability to tense
the vocal cords, which results in the dog’s voice changing to
a weak, hoarse bark (Parnell 2010). Partial obstruction of the
upper airways by the paralysed arytenoids leads to exercise
intolerance (Burbidge 1995; Parnell 2010).
Respiratory distress (which can lead to cyanosis) can easily be
exacerbated by excitement, exercise, elevated environmental
temperatures, pulmonary oedema or the presence of
bronchopneumonia (Millard & Tobias 2009; Monnet &
Tobias 2012; Parnell 2010). The functional airway obstruction
can also be worsened by secondary laryngeal oedema and
inflammation (Harvey & O’Brien 1982; Millard & Tobias
2009). Overweight dogs with LP present with more severe
clinical signs than normally conditioned animals (Broome,
Burbidge & Pfeiffer 2000).
Advanced diagnostics can reveal the presence of concurrent
bronchopneumonia, megaoesophagus, hiatal hernia or
gastro-oesophageal reflux (Burnie, Simpson & Corcoran
1989; Stanley et al. 2010). These can lead to excessive
coughing, gagging and regurgitation in affected patients.
In one study, oesophageal motility was decreased in all 32
dogs with AILP (Stanley et al. 2010). This was a result of a
peripheral neuropathy and was more pronounced if a liquid
diet was fed (Stanley et al. 2010). A decrease in oesophageal
motility can be clinically silent (Stanley et al. 2010).
Dysphagia can be a symptom of peripheral polyneuropathy
and can sometimes be seen in patients with LP (Monnet &
Tobias 2012). Congenital LP in dogs is usually the result of
a polyneuropathy complex and presents in dogs less than
12 months of age (Monnet & Tobias 2012). This form of the
disease is characterised by signs of LP together with lenticular
cataracts and neurological signs such as tetraparesis (worse
in the pelvic limbs), hyporeflexia in all four limbs, decreased
postural reactions, hypotonia and appendicular muscle
atrophy (Braund 1994; Braund et al. 1994; Davies & Irwin
2003; Gabriel et al. 2006; Mahony et al. 1998; Ridyard et al.
2000). Concurrent diseases, such as megaoesophagus and
aspiration pneumonia, can also be present or can develop
during the course of the disease (Braund 1994; Braund et al.
1994; Mahony et al. 1998; Ridyard et al. 2000).
In 15 dogs with AILP that underwent a full physical
neurological examination in one study, all showed
http://www.jsava.co.za
Review Article
neurological abnormalities in addition to respiratory-related
problems (Jeffery et al. 2006). These abnormalities included
decreased postural reactions, deficits in spinal reflexes and
deficits in cranial nerve function (Jeffery et al. 2006). Clinical
signs related to the generalised polyneuropathy can be
subtle and care should be taken as they can be overlooked
when dealing with a dyspnoeic dog (Jeffery et al. 2006).
Neurological dysfunction (ataxia) of the hindlimbs in these
older dogs is often misinterpreted as weakness or as an
orthopaedic condition (Jeffery et al. 2006). This generalised
polyneuropathy is a slowly progressive degenerative
condition that affects peripheral nerves (Stanley et al. 2010).
Obvious clinical signs of general polyneuropathy and
dysphagia can take months to years to develop (Jeffery et al.
2006; Stanley et al. 2010).
Diagnosis
Laryngeal paralysis should be suspected in every patient
displaying inspiratory stridor, hoarse voice changes and
exercise intolerance. The inspiratory dyspnoea does not
resolve with open mouth breathing and will worsen with
mild lateral compression over the larynx (Monnet & Tobias
2012).
Clinical signs and signalment are integral parts when
diagnosing LP. Bouviers des Flandres and Siberian huskies
less than 12 months of age with only respiratory problems
are suspected to suffer from hereditary LP (O’Brien &
Hendriks 1986; Venker-van Haagen 1982). Middle-aged dogs
with respiratory problems consistent with LP combined
with neurological dysfunction are suspected of having
congenital LP, which is mostly the result of a peripheral
polyneuropathy (Monnet & Tobias 2012). Older dogs with
exercise intolerance, inspiratory stridor and dysphonia are
suspected of AILP. The signalment, together with the history,
has a specificity of 91.6% and a sensitivity of 98.5% in all dogs
with grade 3 and 4 laryngeal paralysis (Broome et al. 2000).
Laryngeal inspection is essential in order to rule out other
causes of laryngeal stridor (e.g. laryngeal tumour) and
confirm the suspected diagnosis of LP (Broome et al. 2000).
Direct visualisation of the larynx can be achieved via
transnasal or peroral laryngoscopy. As the latter has a 95%
interobserver agreement, it is considered the gold standard
of diagnosis (Broome et al. 2000; Radlinsky et al. 2009; Smith
2000). Transnasal laryngoscopy has the advantage that it
can be performed in large breed dogs using only sedation
and local anaesthesia (Radlinsky, Mason & Hodgson
2004).
Prior to laryngeal examination, an intravenous catheter is
placed and the dog is preoxygenated for at least 3–5 min
(Millard & Tobias 2009; Smith 2000). The dog is placed
in sternal recumbency and the head is held in a normal
anatomic position (Gross et al. 2002; Jackson et al. 2004; Smith
2000). To prevent a false positive diagnosis, only a light
plane of anaesthesia is maintained (Gross et al. 2002; Jackson
doi:10.4102/jsava.v84i1.909
 Page 4 of 9
et al. 2004; Monnet & Tobias 2012; Smith 2000). The aim is
to achieve relaxation of the jaw muscles without affecting
the laryngeal reflexes or depressing respiratory movements
(Burbidge 1995). Anaesthetic protocols such as diazepam–
ketamine combination are avoided because they result in
suboptimal laryngeal exposure during laryngoscopy as a
result of poor muscle relaxation (Gross et al. 2002). When drug
combinations of acepromazine–propofol, acepromazine–
thiopental or diazepam–ketamine were used, half of the
normal dogs in one study failed to show arytenoid abduction
during inspiration (false positive diagnosis) (Jackson et al.
2004). The same study concluded that intravenous thiopental
as a sole drug was best for maintaining laryngeal function
(Jackson et al. 2004). Although respiratory depression results
when using thiopental as induction agent, a very light plane
of anaesthesia results in tachypnea, which is ideal to evaluate
the larynx (Turner & Ilkiw 1990). Patients suspected of
LP should be examined until they almost reach a plane of
consciousness (Burbidge 1995). When laryngeal inspection is
not conclusive, doxapram HCl (1.1 mg/kg), which induces
deep inspiratory movements, can be useful to differentiate
normal dogs from dogs with LP (Tobias, Jackson & Harvey
2004). The increased velocity of airflow, however, will result
in an increase in the negative airway pressure, which results
in paradoxical arytenoid movement that can lead to complete
laryngeal obstruction (Tobias et al. 2004).
Laryngeal inspection involves the evaluation of the arytenoid
cartilages for active abduction during inspiration and passive
adduction during expiration (Monnet & Tobias 2012).
Immobile arytenoids and vocal cords in an appropriately
anesthetised dog indicate bilateral LP, whereas asymmetrical
motion of the arytenoids is indicative of unilateral disease
(Monnet & Tobias 2012). To avoid false negative diagnoses of
LP in patients with paradoxical movement of the arytenoids,
it is helpful if an assistant indicates the inspiration phase
to the clinician who is performing the laryngeal inspection.
Paradoxical movement in LP patients occurs when the
increased negative airway pressure during inspiration
results in adduction of the arytenoids and, subsequently, the
positive pressure during expiration results in passive return
of the arytenoids to their resting position (Burbidge 1995).
This is encountered in up to 45% of dogs with LP (Olivieri,
Voghera & Fossum 2009). Excessive negative pressure can
lead to secondary elongation of the soft palate and eversion of
the laryngeal saccules (Millard & Tobias 2009). The constant
rubbing of the arytenoid cartilages against each other can
result in mucosal ulcerations and oedema at the level of the
corniculate processes (Monnet & Tobias 2012).
Other diagnostic methods, such as sound signature
identification, tidal breathing flow-volume loops,
electromyography, blood gas analysis and plethysomography,
can assist in confirming the diagnosis of LP (Amis &
Kurpershoek 1986; Bedenice et al. 2006; Burbidge 1995; Yeon
et al. 2005). Echolaryngography has been studied but proved
less sensitive for diagnosing LP than direct visualisation
(Radlinsky et al. 2009; Rudorf, Barr & Lane 2001).
http://www.jsava.co.za
Review Article
Thoracic radiographs should be taken in all dogs suspected of
LP in order to assist in the diagnosis of underlying diseases,
such as cervical and cranial mediastinal masses, and to identify
other pathologies such as megaoesophagus, aspiration
pneumonia and noncardiogenic lung oedema (Monnet
& Tobias 2012). In dogs suspected of a megaoesophagus,
positive contrast oesophograms could confirm the diagnosis;
although, this is not performed routinely because of the
increased risk of aspiration (Millard & Tobias 2009). In
patients with confirmed laryngeal paralysis, 7% – 14% are
subsequently diagnosed with hypothyroidism (Asulp et al.
1997; Dixon, Reid & Mooney 1999; Jaggy et al. 1994; White
1989; Zikes & McCarthy 2012). In dogs showing clinical signs
of weakness, megaoesophagus, other peripheral or central
neurological signs, exercise intolerance, dermatological
abnormalities (hyperpigmentation, alopecia, poor coat
quality and pyoderma), lethargy or obesity, free thyroxine
and thyroid-stimulating hormone should be tested (Jaggy et
al. 1994; Jeffery et al. 2006).
Myasthenia gravis is infrequently associated with LP
(Jeffery et al. 2006). In dogs with LP presenting with clinical
signs of regurgitation (megaoesophagus), dysphagia,
multiple cranial nerve abnormalities, generalised or
focal neuromuscular weakness or exercise intolerances,
acetylcholine receptor antibody titres need to be measured
to rule in or out myasthenia gravis (Shelton 2002). Acquired
myasthenia gravis can be associated with hypothyroidism
or hypoadrenocorticism, or present as paraneoplastic
syndrome associated with thymomas, osteogenic sarcoma,
cholangiocellular carcinoma and cutaneous lymphoma
(Shelton 2002). An attempt should be made to rule out these
primary conditions when a diagnosis of myasthenia gravis
has been made.
Medical treatment of respiratory
distress
Patients with LP can present in acute respiratory distress,
resulting in cyanosis and hyperthermia (Burbidge 1995).
Emergency treatment is essential and consists of oxygen
supplementation, administration of a sedative and cooling of
the patient (Burbidge 1995; Millard & Tobias 2009). The route
of oxygen supplementation depends on what is tolerated by
the patient and can include an oxygen cage, flow-by oxygen,
an oxygen hood, a facemask or a nasal cannula (Mazzaferro
2009). If cyanosis, dyspnoea and hypoxia (SPO2 < 95%) persist
despite oxygen supplementation, a temporary tracheostomy
or temporary intubation under light anaesthesia should be
considered until laryngeal swelling decreases or surgical
correction can be performed (Millard & Tobias 2009).
Temporary intubation is selected if the time of intubation is
expected to be just a couple of hours, whereas tracheostomy
tubes are used for longer-term management (Millard &
Tobias 2009). Fluids are administered with caution as
pulmonary oedema can develop in animals with severe
upper respiratory tract obstruction (Monnet & Tobias 2012).
Sedation using acepromazine (0.005 mg/kg – 0.020 mg/kg)
doi:10.4102/jsava.v84i1.909
 Page 5 of 9
and butorphanol (0.200 mg/kg – 0.400 mg/kg) has been
recommended (Millard & Tobias 2009). Additionally,
short-acting corticosteroids, such as dexamethasone
(0.100 mg/kg – 0.500 mg/kg) or prednisolone sodium succinate
(0.200 mg/kg – 0.400 mg/kg), can be administered in the case
of laryngeal oedema (Millard & Tobias 2009). Hyperthermia
should be differentiated from true pyrexia that can occur as
a result of aspiration pneumonia. Temperatures lower than
41.0 °C are not life threatening unless prolonged and therapy
to cool patients should only be instituted if temperatures are
elevated above this level (Mazzaferro 2009; Millard & Tobias
2009). Cooling can be achieved by clipping the fur, by wetting
the animal, by applying ice packs over well-vascularised
regions (neck, axilla and inguinal region), by fanning the
wetted patient or by the rectal administration of cool isotonic
fluids (Mazzaferro 2009). Continuous monitoring of the
temperature is important and cooling procedures should
be discontinued as soon as the body temperature reaches
39.4 °C to prevent iatrogenic hypothermia (Mazzaferro 2009).
Conservative management of LP can be considered in older
patients with minimal to moderate clinical signs. This involves
anti-inflammatory drugs to decrease laryngeal swelling and
a weight loss programme for overweight patients (MacPhail
& Monnet 2008). The owners should also be educated on the
changes in the patient’s routine and environment. A cool
area should be prepared for the patient, especially in the
warmer months of the year. Patients should not be allowed
to perform strenuous exercise. Short walks using a harness
can be permitted during the cooler periods of the day.
Surgical treatment by cricoarytenoid
cartilage lateralisation
Surgical management is advised in all LP patients with
severe clinical signs (MacPhail & Monnet 2008; Monnet
& Tobias 2012). The aim of surgery is to increase the size
of the rima glottidis (LaHue 1989; Millard & Tobias 2009;
Monnet & Tobias 2012). As resistance of airflow is inversely
proportional to the radius to the power of four, according
to Poiseuille’s law, even a small increase in size will make a
substantial difference (Monnet & Tobias 2012).
Many surgical techniques have been developed and
successfully applied. They can be classified as intra-
laryngeal or extra-laryngeal procedures (Figures 2 and 3).
Cricoarytenoid cartilage lateralisation is currently considered
the procedure of choice (Monnet & Tobias 2012). The
objective of this procedure is to prevent passive adduction
of the arytenoid cartilage during inspiration by fixing it
to a neutral to slightly lateralised position (low tension
technique) (Bureau & Monnet 2002). This modification still
allows adequate epiglottic coverage of the rima glottidis
during swallowing and is believed to reduce aspiration-
related complications (Bureau & Monnet 2002).
Unilateral cricoarytenoid lateralisation (UCAL) is performed
via a lateral approach (LaHue 1989; Monnet & Tobias
http://www.jsava.co.za
Review Article
2012). Dogs with unilateral LP are corrected depending on
the affected side, whilst dogs with bilateral LP have the
lateralisation procedure on the left side if the surgeon is right-
handed (MacPhail & Monnet 2001; Monnet & Tobias 2012).
Unilateral correction is sufficient to relieve clinical signs in
most bilaterally affected dogs (Monnet & Tobias 2012).
Placing a sandbag under the neck elevates the laryngeal
region and the skin incision is made over the larynx, just
ventral to the jugular vein (Monnet & Tobias 2012). A
combination of blunt and sharp dissection through the
subcutaneous muscles (platysma and superficial sphincter
colli muscles) and subcutaneous tissue exposes the TP
muscle. This is then incised at the dorsocaudal rim of the
lamina of the thyroid cartilage, avoiding penetration of the
laryngeal mucosa. Alternatively, the TP muscle can be split
along the direction of its muscle fibres (Nelissen & White
2011). Cricothyroid disarticulation may be performed in
the adult dog when additional exposure is required. As an
alternative, a stay suture can be placed through the lamina of
the thyroid cartilage to achieve atraumatic lateral retraction.
The muscular process of the arytenoid cartilage is usually
prominent and easily palpable because of the neurogenic
atrophy of the CAD muscle (Griffin & Krahwinkel 2005). A
transverse incision is made through the CAD muscle and
dissection is continued carefully until the cricoarytenoid
articulation is visible (Monnet & Tobias 2012). The cranial
With
ventriculocordectomy
Partial
laryngectomy
Without
Intra-laryngeal
Implant
ventriculocordectomy
augmentation
With
ventriculocordectomy
Castellated
laryngofissure
Without
ventriculocordectomy
FIGURE 2: Schematic diagram indicating the different intra-laryngeal surgical
procedures in dogs with laryngeal paralysis.
Cricoarytenoid
lateralisation
Arytenoid Thyroarytenoid
lateralisation lateralisation
Cricothyroarytenoid
lateralisation
Extra-laryngeal
Neuromuscular
pedicle grafts
Reinnnervation
Nerve anastomosis
FIGURE 3: Schematic diagram indicating the different extra-laryngeal surgical
procedures in dogs with laryngeal paralysis.
doi:10.4102/jsava.v84i1.909
 Page 6 of 9 Review Article

part of the joint capsule is left intact during dissection of avoidance of laryngeal lumen penetration (Monnet & Tobias
the cricoarytenoid joint (Bureau & Monnet 2002). A non- 2012). Factors that negatively influence the surgical outcome
absorbable monofilament suture (e.g. polypropylene) on a include age, concurrent respiratory tract abnormalities,
tapercut needle is recommended for fixing the arytenoid. oesophageal disease, neurological disease or neoplastic
Depending on the size of the dog, USP 2/0 (< 40 kg) or USP disease and the placement of a temporary tracheostomy
0 (> 40 kg) is used (Demetriou & Kirby 2003). The suture tube (MacPhail & Monnet 2001). Unilateral cricoarytenoid
is anchored dorsally on the caudal border of the cricoid lateralisation has a good clinical outcome, with 88% – 90% of
cartilage, taking care not to penetrate the laryngeal lumen. It is dogs showing an improved quality of life in the postoperative
recommended that extubation be attempted after performing period (Hammel et al. 2006; Snelling & Edwards 2003).
this step as inadvertent suturing of the endotracheal tube
Variations of this technique exist in which the arytenoid is
can occur (Weinstein & Weisman 2010). The needle is then
also fixed to the thyroid (cricothyroarytenoid lateralisation)
passed through the muscular process of the arytenoid in a
or solely to the thyroid (thyroarytenoid lateralisation)
medial-to-lateral direction (Monnet & Tobias 2012). Older
(Monnet & Tobias 2012). The latter technique results in a
dogs can have brittle laryngeal cartilages that can tear during
less extensive (but satisfactory) opening of the rima glottidis
suture placement (Monnet & Tobias 2012). For this reason,
needle selection is very important to decrease the risk of when compared to cricoarytenoid lateralisation and takes
tearing or even fracturing of the cartilage once the suture is less time to perform (Griffiths, Sullivan & Reid 2001). The
tightened. Some authors advise pre-drilling a small hole in clinical outcomes of UCAL and thyroarytenoid lateralisation
the arytenoid cartilage using an 18-gauge hypodermic needle compare well (Griffiths et al. 2001).
before needle placement (Monnet & Tobias 2012).
Other surgical techniques
The suture is carefully tied until resistance from the tensed
Permanent tracheostomy creates a bypass of the larynx
remaining part of the joint capsule is felt (Bureau & Monnet
(Monnet & Tobias 2012). It is considered in patients that are
2002). Alternatively, the suture can be tied under direct visual
endoscopic control after temporary extubation (Weinstein &
Weisman 2010). Adequate abduction is defined as any degree
of abduction resulting in an increase in the glottic diameter a
without axial displacement of the dependant (non-surgically
treated) side (Weinstein & Weisman 2010) (Figure 4).
Meticulous apposition of the TP muscle, using a continuous
suture pattern with monofilament absorbable suture material
is essential to decrease the chance for postoperative dysphagia
(Nelissen & White 2011). The subcutaneous tissues are closed
in two layers and the skin is closed routinely.

Postoperative complications occur in 10% – 58% of dogs

(Gaber et al. 1985; Hammel, Hottinger & Novo 2006; MacPhail
& Monnet 2001; Snelling & Edwards 2003). These include
gagging or coughing, aspiration pneumonia, recurrence of
clinical signs (caused by implant failure or cartilage tearing),
residual stridor, respiratory distress, gastric dilatation
volvulus, seroma or haematoma formation, and death (Millard
& Tobias 2009; Monnet & Tobias 2012). It should be kept in b
mind that dogs carry a lifelong risk for the development of
respiratory tract complications postoperatively (MacPhail &
Monnet 2001). Aspiration pneumonia is the most frequently
noted complication, occurring in about 8% – 24% of dogs
postoperatively (Demetriou & Kirby 2003; Hammel et al. 2006;
MacPhail & Monnet 2001; Snelling & Edwards 2003; White
1989). Low-tension techniques are believed to decrease the
incidence of postoperative aspiration pneumonia (Bureau &
Monnet 2002).

About 5% of patients require a contralateral procedure because

of arytenoid fragmentation, avulsion of the lateralisation
suture or inadequate lateralisation (White 1989). Recurrence
of clinical signs postoperatively is seen more commonly in
Source: Photographs by B. Van Goethem
small breed dogs (Snelling & Edwards 2003). Complications
during the postoperative period can be minimised by sound FIGURE 4: Laryngeal inspection in a 10-year-old Maltese dog with laryngeal
paralysis, depicting, (a) preoperative appearance and (b) left arytenoid
knowledge of the anatomy, meticulous tissue handling and abduction after unilateral arytenoid lateralisation.

http://www.jsava.co.za doi:10.4102/jsava.v84i1.909
 Page 7 of 9 Review Article

at risk for postoperative aspiration pneumonia. This includes experimentally denervated patients (Greenfield et al. 1988;
patients with generalised myopathy, megaoesophagus, Paniello, West & Lee 2001; Rice 1982). These techniques might
hiatal hernia and gastrointestinal disorders (Monnet & be of use in patients with acquired LP of traumatic origin. It
Tobias 2012). is likely to be ineffective in patients with polyneuropathy or
polymyopathy as a primary cause (Monnet & Tobias 2012).
Partial laryngectomy (Figure 5) is an older technique Its routine use is also questioned as it takes a minimum of
involving removal of the vocal cords and a substantial 5 months for restoration of laryngeal function (Greenfield
part of the corniculate and vocal processes (unilateral or et al. 1988).
bilateral) in order to ensure unobstructed airflow without
influencing the protective effect on the airway (Harvey
Laryngeal augmentation with implantable devices has been
1983a, 1983b). This procedure can result in significant
reported ex vivo (Cabano et al. 2011) and in vivo (Kwon et al.
postoperative swelling that might necessitate placement
2007) in canine patients. No extensive clinical data exist for
of a temporary tracheostomy tube. Complications are seen
in approximately 50% of the dogs and include persistent the current devices and hence their use can currently not be
upper respiratory stridor, coughing, vomiting, aspiration recommended.
pneumonia, laryngeal webbing and exercise intolerance
(Harvey 1983a; Harvey & O’Brien 1982; MacPhail & Monnet
2001; Ross et al. 1991) (Table 1). This abandoned technique
has recently regained popularity since the introduction of
diode laser arytenoidectomy via transoral approach. No
direct postoperative complications were reported in 20 dogs
and only 10% developed aspiration pneumonia in the long 1
term (Olivieri et al. 2009).

A recent retrospective study on ventriculocordectomy via

ventral laryngotomy has shown some promising results with
limited short-term and long-term complications. The authors
of this article concluded that because of the ease of the
procedure, the limited complications and minimal surgical
trauma, this technique should be considered for routine use
(Zikes & McCarthy 2012). 2

Castellated laryngofissure is another historical procedure

that creates an enlargement of the ventral laryngeal ostium by
offset closure of a castellated incision on the ventral aspect of
the thyroid cartilage (Figure 6). This procedure is technically
difficult, results in severe postoperative laryngeal oedema
and requires the placement of a temporary tracheostomy
tube for 2–3 days postoperatively (Monnet & Tobias 2012).
Variable results have been obtained and the procedure was
abandoned (Burbidge et al. 1991). Source: Photograph by M. Doom
FIGURE 5: Schematic presentation of unilateral partial laryngectomy on an
Reinnervation techniques and neuromuscular pedicle grafts embalmed cadaver specimen of the canine larynx, indicating the area of the
arytenoid cartilage to be removed in blue (1) and the location of the vocal fold
have been used in dogs to restore the abductor function in in red (2).

TABLE 1: Surgical treatment methods with their reported percentages of improvement, aspiration pneumonia, minor complications (persistent stridor, coughing, gagging,
panting, seroma formation, exercise intoler ance or vomiting), webbing and mortality rate.
Treatment method Improvement Aspiration pneumonia Minor complications Webbing Mortality
(%) (%) (%) (%) (%)
Unilateral arytenoid lateralisation1,2,3,4,5 90 10–28 9–56 - 0–14
Bilateral arytenoid lateralisation6,4 - 11–89  - - 67
Bilateral arytenoid lateralisation with ventriculocordectomy7 88 15 30  - 0
Castellated laryngofissure with ventriculocordectomy6 100 - 40 40  -
Partial laryngectomy, transoral approach with or without 88–90 6–33 44 8–14 30
ventriculocordectomy4,8,9
Partial laryngectomy, transoral approach – diode laser10 100 10  - 0 -
Ventriculocordectomy, transoral approach11,12 83 15 40–73 13  -
Ventriculocordectomy, ventral approach13 93 3 6 0  -
1
, Demetriou and Kirby (2003); 2, Griffiths et al. (2001); 3, Hammel et al. (2006); 4, MacPhail and Monnet (2001); 5, White (1989); 6, Burbridge et al. (1998); 7, Schofield et al. (2007); 8, Ross et al.
(1991); 9, Trout et al. (1994); 10, Olivieri et al. (2009); 11, Asulp et al. (1997); 12, Holt and Harvey (1994); 13, Zikes and McCarthy (2012).
For more information on these sources, please see the full reference list of the article, Kitshoff, A.M., Van Goethem, B., Stegen, L., Vandekerckhove, P. & De Rooster, H., 2013, ‘Laryngeal paralysis
in dogs: An update on recent knowledge’, Journal of the South African Veterinary Association 84(1), Art. #909, 9 pages. http://dx.doi.org/10.4102/jsava.v84i1.909

http://www.jsava.co.za doi:10.4102/jsava.v84i1.909
 Page 8 of 9
a b
After incision of the cartilage, the flap located at 2 is advanced and positioned lateral to 1, as
shown. The cranial border of the cranially advanced thyroid cartilage segment (*) is sutured
to the basihyoid (3) with two simple interrupted 2/0 monofilament non-absorbable sutures.
The apposed edges in the rostral third (between 1 and 2) are also sutured using the same
suture material.
FIGURE 6: Schematic presentation of the castellated laryngofissure technique,
depicting, (a) the ventral view of the thyroid cartilage indicating the stepped
incision and (b) the advancement of the cartilage flap.
Postoperative care
After surgical treatment, partial obstruction of the larynx
will be relieved and the respiratory dyspnoea will resolve
immediately. Oxygen therapy should be administered
as necessary and perioperative dexamethasone sodium
phosphate (0.1 mg/kg – 1.0 mg/kg) can be helpful to decrease
laryngeal swelling and oedema (Monnet & Tobias 2012). Food
and water is withheld until 12 h after the operation. Heavy
sedation in the postoperative period is avoided to preserve
the swallowing reflexes (Monnet & Tobias 2012). The patient
is first offered canned food rolled into balls (Monnet & Tobias
2012). If no coughing or gagging is observed, small amounts
of water can be offered (Monnet & Tobias 2012). The decision
to administer postoperative antibiotic is usually case based.
Prognosis and conclusion
A clear distinction needs to be made between the different
forms of the disease. Prognosis for hereditary LP is excellent
as dogs are cured by surgery. Congenital LP neuropathy
has a poor prognosis and most dogs tend to be euthanased
within 10 weeks as a result of worsening clinical signs
(Davies & Irwin 2003). The prognosis for acquired LP will
vary depending on the cause: trauma cases can be cured;
neoplasia-induced LP will depend on the tumour type.
Evidence strongly suggests that the most common form of
LP in dogs is, in fact, an early stage of GOLPP (Stanley et al.
2010). Even though all complications should be considered
when making a prognosis in any dog developing LP as a
component of polyneuropathy, this condition progresses
slowly, making short-term prognosis more favourable.
Acknowledgements
The authors would like to the Department of Morphology
at the Faculty of Veterinary Medicine, Ghent University for
supplying the embalmed canine larynxes for the photographs
shown in Figures 1 and 5.
http://www.jsava.co.za
Review Article
Competing interests
The authors declare that they have no financial or personal
relationships which may have inappropriately influenced
them in writing this article.
Authors’ contributions
A.M.K. (University of Ghent) wrote the manuscript.
H.d.R. (University of Ghent), B.v.G. (University of Ghent),
L.S. (University of Ghent) and P.V. (Veterinary Centre
Malpertuus) made conceptual contributions.
References
Amis, T.C. & Kurpershoek, C., 1986, ‘Tidal breathing flow-volume loop analysis for
clinical assessment of airway obstruction in conscious dogs’, American Journal of
Veterinary Research 47, 1002–1006. PMid:3717718
Alsup, J.C., Greenfeld, C.L., Hungerford, McKiernan, B.C. & Whiteley, H.E.,
1997, ‘Comparison of unilateral arytenoid lateralization and ventral
ventriculocordectomy for the treatment of experimentally induced laryngeal
paralysis in dogs’, Canadian Veterinary Journal 38(5), 287–293.
Bedenice, D., Rozanski, E., Bach, J., Lofgren, J. & Hoffman, A.M., 2006, ‘Canine awake
head-out plethysmography (HOP): Characterization of external resistive loading
and spontaneous laryngeal paralysis’, Respiratory Physiology and Neurobiology
151, 61–73. http://dx.doi.org/10.1016/j.resp.2005.05.030, PMid:16055393
Bennnett, P.F. & Clarke, R.E., 1997, ‘Laryngeal paralysis in a Rottweiler with
neuroaxonal dystrophy’, Australian Veterinary Journal 75, 784–786. http://dx.doi.
org/10.1111/j.1751-0813.1997.tb15650.x
Braund, K.G., 1994, ‘Pediatric neuropathies’, Seminars in Veterinary Medicine and
Surgery (Small Animal) 9, 86–98.
Braund, K.G., Shores, A., Cochrane, S., Forrester, D., Kwiecien, J.M. & Steiss, J.E., 1994,
‘Laryngeal paralysis-polyneuropathy complex in young Dalmations’, American
Journal of Veterinary Research 55, 534–542. PMid:8017700
Braund, K.G., Steinberg, H.S., Shores, A., Steiss, J.E., Mehta, J.R., Toiviokinnucan, M. et
al., 1989, ‘Laryngeal paralysis in immature and mature dogs as one sign of a more
diffuse polyneuropathy’, Journal of the American Veterinary Medical Association
194, 1735–1740. PMid:2546908
Broome, C., Burbidge, H.M. & Pfeiffer, D.U., 2000, ‘Prevalence of laryngeal paresis in
dogs undergoing general anaesthesia’, Australian Veterinary Journal 78, 769–772.
http://dx.doi.org/10.1111/j.1751-0813.2000.tb10449.x, PMid:11194723
Burbidge, H., 1995, ‘A review of laryngeal paralysis in dogs’, British Veterinary Journal
151, 71–82. http://dx.doi.org/10.1016/S0007-1935(05)80066-1
Burbidge, H.M., Goulden, E. & Jones, B.R., 1991, ‘An experimental evaluation of
castellated laryngofissure and bilateral arytenoid lateralisation for the relief of
laryngeal paralysis in dogs’, Australian Veterinary Journal 68, 268–272. http://
dx.doi.org/10.1111/j.1751-0813.1991.tb03239.x, PMid:1953550
Bureau, S. & Monnet, E., 2002, ‘Effects of suture tension and surgical approach during
unilateral arytenoid lateralization on the rima glottidis in the canine larynx’,
Veterinary Surgery 31, 589–595. http://dx.doi.org/10.1053/jvet.2002.34671,
PMid:12415529
Burnie, A., Simpson, J. & Corcoran, B., 1989, ‘Gastrooesophageal reflux and hiatus-
hernia associated with laryngeal paralysis in a dog’, Journal of Small Animal
Practice 30, 414–416. http://dx.doi.org/10.1111/j.1748-5827.1989.tb01595.x
Cabano, N.R., Greenberg, M.J., Bureau, S. & Monnet, E., 2011, ‘Effects of bilateral
arytenoid cartilage stenting on canine laryngeal resistance ex vivo’, Veterinary
Surgery 40, 97–101. http://dx.doi.org/10.1111/j.1532-950X.2010.00753.x,
PMid:21062323
Davies, D.R. & Irwin, P.J., 2003, ‘Degenerative neurological and neuromuscular disease
in young rottweilers’, Journal of Small Animal Practice 44, 388–394. http://dx.doi.
org/10.1111/j.1748-5827.2003.tb00173.x, PMid:14510327
Demetriou, J.L. & Kirby, B.M., 2003, ‘The effect of two modifications of unilateral
arytenoid lateralization on rima glottidis area in dogs’, Veterinary Surgery 32,
62–68. http://dx.doi.org/10.1053/jvet.2003.50000, PMid:12520491
Dewey, C., Bailey, C., Shelton, G., Kass, P. & Cardinet, G., 1997, ‘Clinical forms of
acquired myasthenia gravis in dogs: 25 cases (1988–1995)’, Journal of Veterinary
Internal Medicine 11, 50–57. http://dx.doi.org/10.1111/j.1939-1676.1997.
tb00073.x, PMid:9127290
Dixon, R.M., Reid, S.W.J. & Mooney, C.T., 1999, ‘Epidemiological, clinical and
biochemical characteristics of canine hypothyroidism’, Veterinary Record 145,
481–487.
Eger, C.E., Huxtable, C.R.R., Chester, Z.C. & Summers, B.A., 1998, ‘Progressive
tetraparesis and laryngeal paralysis in a young Rottweiler with neuronal
vacuolation and axonal degeneration: An Australian case’, Australian Veterinary
Journal 76, 733–737. http://dx.doi.org/10.1111/j.1751-0813.1998.tb12301.x,
PMid:9862062
Evans, H.E., 1993, ‘The respiratory system’, in M.E. Miller & H.E. Evans (eds.), Miller’s
anatomy of the dog, 3rd edn., pp. 463–493, Saunders, Philadelphia. PMid:8403598
Evans, H.E. & Kitchell, R.L., 1993, ‘Cranial nerves and cutaneous innervation of the
head’, in M.E. Miller & H.E. Evans (eds.), Miller’s anatomy of the dog, 3rd edn., pp.
953–987, Saunders, Philadelphia.
doi:10.4102/jsava.v84i1.909
 Page 9 of 9
Gaber, C., Amis, T. & Le Couteur, R., 1985, ‘Laryngeal paralysis in dogs – A review of
23 cases’, Journal of the American Veterinary Medical Association 186, 377–380.
PMid:3972696
Gabriel, A., Poncelet, L., Van Ham, L., Clercx, C., Braund, K.G., Bhatti, S. et al.,
2006, ‘Laryngeal paralysis-polyneuropathy complex in young related Pyrenean
mountain dogs’, Journal of Small Animal Practice 47, 144–149. http://dx.doi.
org/10.1111/j.1748-5827.2006.00058.x, PMid:16512846
Greenfield, C.L., Walshaw, R., Kumar, K., Lowrie, C.T. & Derksen, F.J., 1988,
‘Neuromuscular pedicle graft for restoration of arytenoid abductor function in
dogs with experimentally induced laryngeal hemiplegia’, American Journal of
Veterinary Research 49, 1360–1366. PMid:3178033
Griffin, J. & Krahwinkel, D., 2005, ‘Laryngeal paralysis: Pathophysiology, diagnosis,
and surgical repair’, Compendium on Continuing Education for the Practicing
Veterinarian 27, 857–869.
Griffiths, L.G., Sullivan, M. & Reid, S.W., 2001, ‘A comparison of the effects of unilateral
thyroarytenoid lateralization versus cricoarytenoid laryngoplasty on the area of
the rima glottidis and clinical outcome in dogs with laryngeal paralysis’, Veterinary
Surgery 30, 359–365. http://dx.doi.org/10.1111/j.1532-950X.2001.00359.x,
PMid:11443597
Gross, M.E., Dodam, J.R., Pope, E.R. & Jones, B.D., 2002, ‘A comparison of thiopental,
propofol, and diazepam-ketamine anesthesia for evaluation of laryngeal function
in dogs premedicated with butorphanol-glycopyrrolate’, Journal of the American
Animal Hospital Association 38, 503–506. PMid:12428879
Hammel, S.P., Hottinger, H.A. & Novo, R.E., 2006, ‘Postoperative results of unilateral
arytenoid lateralization for treatment of idiopathic laryngeal paralysis in dogs: 39
cases (1996–2002)’, Journal of the American Veterinary Medical Association 228,
1215–1220. http://dx.doi.org/10.2460/javma.228.8.1215, PMid:16618225
Harvey, C.E., 1983a, ‘Partial laryngectomy in the dog I. Healing and swallowing
function in normal dogs’, Veterinary Surgery 12, 192–196. http://dx.doi.
org/10.1111/j.1532-950X.1983.tb00741.x
Harvey, C.E., 1983b, ‘Partial laryngectomy in the dog II. Immediate increase in glottic
area obtained compared with other laryngeal procedures’, Veterinary Surgery 12,
197–201. http://dx.doi.org/10.1111/j.1532-950X.1983.tb00742.x
Harvey, C.E. & O’Brien, J.A., 1982, ‘Treatment of laryngeal paralysis in dogs by partial
laryngectomy’, Journal of the American Animal Hospital Association 18, 551–556.
Hermanson, J.W. & Evans, H.E., 1993, ‘The muscular system’, in M.E. Miller & H.E.
Evans (eds.), Miller’s anatomy of the dog, 3rd edn., pp. 258–384, Saunders,
Philadelphia.
Holt, D. & Harvey, C., 1994, ‘Idiopathic laryngeal paralysis: Results of treatment by
bilateral vocal fold resection in 40 dogs’, Journal of the American Animal Hospital
Association 30, 389–395.
Jackson, A.M., Tobias, K., Long, C., Bartges, J. & Harvey, R., 2004, ‘Effects of
various anesthetic agents on laryngeal motion during laryngoscopy in normal
dogs’, Veterinary Surgery 33, 102–106. http://dx.doi.org/10.1111/j.1532-
950x.2004.04016.x, PMid:15027970
Jaggy, A., Oliver, J.E., Ferguson, D.C., Mahaffrey, E.A. & Jun, T.G., 1994, ‘Neurological
manifestations of hypothyroidism: A retropsective study of 29 dogs’, Journal of
Veterinary Medicine 8(5), 328–336.
Jeffery, N.D., Talbot, C.E., Smith, P.M. & Bacon, N.J., 2006, ‘Acquired idiopathic
laryngeal paralysis as a prominent feature of generalised neuromuscular disease
in 39 dogs’, Veterinary Record 158, 17–21. http://dx.doi.org/10.1136/vr.158.1.17,
PMid:16400098
Kvitko-White, H., Balog, K., Scott-Moncrieff, J.C., Johnson, A. & Lantz, G.C.,
2012, ‘Acquired bilateral laryngeal paralysis associated with systemic lupus
erythematosus in a dog’, Journal of the American Animal Hospital Association
48(1), 60–65.
Kwon, T.K., Jeong, W.J., Sung, M.W. & Kim, K.H., 2007, ‘Development of endoscopic
arytenoid adduction using cricoid implant’, Annals of Otology, Rhinology and
Laryngology 116, 770–778. PMid:17987783
LaHue, T.R., 1989, ‘Treatment of laryngeal paralysis in dogs by unilateral cricoarytenoid
laryngoplasty’, Journal of the American Animal Hospital Association 25, 317–324.
MacPhail, C.M. & Monnet, E., 2001, ‘Outcome of and postoperative complications
in dogs undergoing surgical treatment of laryngeal paralysis: 140 cases (1985–
1998)’, Journal of the American Veterinary Medical Association 218, 1949–1956.
http://dx.doi.org/10.2460/javma.2001.218.1949, PMid:11417740
MacPhail, C.M. & Monnet, E., 2008, ‘Laryngeal paralysis’, in J.D. Bonagura & R.W.
Kirk (eds.), Kirk’s current veterinary therapy, pp. 627–630, Elsevier Saunders,
Philadelphia.
Mahony, O.H., Knowles, K.E., Braund, K.G., Averill, D.R. & Frimberger, A.E.,
1998, ‘Laryngeal paralysis-polyneuropathy complex in young Rottweilers’,
Journal of Veterinary Internal Medicine 12, 330–337. http://dx.doi.
org/10.1111/j.1939-1676.1998.tb02131.x, PMid:9773408
Mazzaferro, E.M., 2009, ‘Oxygen therapy’, in D.C. Silverstein & K. Hopper (eds.), Small
animal critical care medicine, pp. 78–81, Elsevier Saunders, St. Louis. http://
dx.doi.org/10.1016/B978-1-4160-2591-7.10019-0
Michael, P., 2002, ‘Inflammatory myopathies’, Veterinary Clinics of North America:
Small Animal Practice 32, 147–167. http://dx.doi.org/10.1016/S0195-
5616(03)00083-4
Millard, R.P. & Tobias, K.M., 2009, ‘Laryngeal paralysis in dogs’, Compendium on
Continuing Education for the Practicing Veterinarian 31, 212–219.
Monnet, E. & Tobias, K.M. 2012, ‘Larynx’, in K.M. Tobias & S.A. Johnston (eds.),
Veterinary surgery small animal, vol. 2, pp. 1718–1733, Elsevier Saunders, St.
Louis.
http://www.jsava.co.za
Review Article
Nelissen, P. & White, R.A., 2011, ‘Arytenoid lateralization for management of
combined laryngeal paralysis and laryngeal collapse in small dogs’, Veterinary
Surgery 41, 261–265. PMid:22103399
O’Brien, J.A. & Hendriks, J., 1986, ‘Inherited laryngeal paralysis. Analysis in the husky
cross’, Veterinary Qauterly 8, 301–302. http://dx.doi.org/10.1080/01652176.198
6.9694059, PMid:3798712
Olivieri, M., Voghera, S.G. & Fossum, T.W., 2009, ‘Video-assisted left partial
arytenoidectomy by diode laser photoablation for treatment of canine laryngeal
paralysis’, Veterinary Surgery 38, 439–444. http://dx.doi.org/10.1111/j.1532-
950X.2009.00546.x, PMid:19538663
Paniello, R.C., West, S.E. & Lee, P., 2001, ‘Laryngeal reinnervation with the hypoglossal
nerve. I. Physiology, histochemistry, electromyography, and retrograde labeling
in a canine model’, Annals of Otology, Rhinology and Laryngology 110, 532–542.
PMid:11407844
Parnell, N.K., 2010, ‘Diseases of the throat’, in S.J. Ettinger & E.C. Feldman (eds.),
Textbook of veterinary internal medicine: Diseases of the dog and the cat, 7th
edn., vol. 1, pp. 1040–1047, Elsevier Saunders, St. Louis.
Polizopoulou, Z.S., Koutinas, A.F., Papadopoulos, G.C. & Saridomichelakis, M.N., 2003,
‘Juvenile laryngeal paralysis in three Siberian husky x Alaskan malamute puppies’,
Veterinary Record 153, 624–627. http://dx.doi.org/10.1136/vr.153.20.624,
PMid:14653342
Radlinsky, M.G., Mason, D.E. & Hodgson, D., 2004, ‘Transnasal laryngoscopy for the
diagnosis of laryngeal paralysis in dogs’, Journal of the American Animal Hospital
Association 40, 211–215. PMid:15131101
Radlinsky, M.G, Williams, J., Frank, P.M. & Cooper, T.C., 2009, ‘Comparison of three
clinical techniques for the diagnosis of laryngeal paralysis in dogs’, Veterinary
Surgery 38, 434–438. http://dx.doi.org/10.1111/j.1532-950X.2009.00506.x,
PMid:19538662
Rice, D.H., 1982, ‘Laryngeal reinnervation’, Laryngoscope 92, 1049–1059. http://
dx.doi.org/10.1288/00005537-198209000-00016, PMid:7121159
Ridyard, A.E., Corcoran, B.M., Tasker, S., Willis, R., Welsh, E.M., Demetriou, J.L.
et al., 2000, ‘Spontaneous laryngeal paralysis in four white-coated German
shepherd dogs’, Journal of Small Animal Practice 41, 558–561. http://dx.doi.
org/10.1111/j.1748-5827.2000.tb03153.x, PMid:11138855
Ross, J.T., Matthiesen, D.T., Noone, K.E. & Scavelli, T.A., 1991, ‘Complications and long-
term results after partial laryngectomy for the treatment of idiopathic laryngeal
paralysis in 45 dogs’, Veterinary Surgery 20, 169–173. http://dx.doi.org/10.1111/
j.1532-950X.1991.tb00330.x, PMid:1853548
Rudorf, H., Barr, F.J. & Lane, J.G., 2001, ‘The role of ultrasound in the assessment of
laryngeal paralysis in the dog’, Veterinary Radiology and Ultrasound 42, 338–343.
http://dx.doi.org/10.1111/j.1740-8261.2001.tb00949.x, PMid:11499709
Schofield, D.M., Norris, J. & Sadanaga, K.K., 2007, ‘Bilateral thyroarytenoid cartilage
lateralization and vocal fold excision with mucosoplasty for treatment of
idiopathic laryngeal paralysis: 67 dogs (1998–2005)’, Veterinary Surgery 36(6),
519–525. http://dx.doi.org/10.1111%2Fj.1532-950X.2007.00302.x
Shelton, G.D., 2002, ‘Myasthenia gravis and disorders of neuromuscular transmission’,
Veterinary Clinics of North America: Small Animal Practice 32(1), 189–206.
Smith, M.M., 2000, ‘Diagnosing laryngeal paralysis’, Journal of the American Animal
Hospital Association 36, 383–384. PMid:10997511
Snelling, S.R. & Edwards, G.A., 2003, ‘A retrospective study of unilateral
arytenoid lateralisation in the treatment of laryngeal paralysis in 100 dogs
(1992–2000)’, Australian Veterinary Jouranl 81, 464–468. http://dx.doi.
org/10.1111/j.1751-0813.2003.tb13361.x, PMid:15086080
Stanley, B.J., Hauptman, J.G., Fritz, M.C., Rosenstein, D.S. & Kinns, J., 2010,
‘Esophageal dysfunction in dogs with idiopathic laryngeal paralysis: A controlled
cohort study’, Veterinary Surgery 39, 139–149. http://dx.doi.org/10.1111/j.1532-
950X.2009.00626.x, PMid:20210960
Tobias, K.M., Jackson, A.M. & Harvey, R.C., 2004, ‘Effects of doxapram HCl on laryngeal
function of normal dogs and dogs with naturally occurring laryngeal paralysis’,
Veterinary Anaesthesia and Analgesia 31, 258–263. http://dx.doi.org/10.1111/
j.1467-2995.2004.00168.x, PMid:15509290
Trout, N.J., Harpster, N.K., Berg, J. & Carpenter, J., 1994, ‘Long-term results of uliateral
ventriculocordectomy and partial arytenoidectomy for the treatment of laryngeal
paralysis in 60 dogs’, Journal of the American Animal Hospital Association 30,
401–407.
Turner, D.M. & Ilkiw, J.E., 1990, ‘Cardiovascular and respiratory effects of three rapidly
acting barbiturates in dogs’, American Journal of Veterinary Research 51, 598–
604. PMid:2327623
Venker-van Haagen, A.J., 1982, ‘Laryngeal paralysis in bouviers Belge des Flandres and
breeding advice to prevent this condition’, Tijdschrift voor Diergeneeskunde 107,
21–22. PMid:7054920
Weinstein, J. & Weisman, D., 2010, ‘Intraoperative evaluation of the larynx following
unilateral arytenoid lateralization for acquired idiopathic laryngeal paralysis
in dogs’, Journal of the American Animal Hospital Association 46, 241–248.
PMid:20610696
White, R.A.S., 1989, ‘Unilateral arytenoid lateralisation: An assessment of technique
and long term results in 62 dogs with laryngeal paralysis’, Journal of Small Animal
Practice 30, 543–549. http://dx.doi.org/10.1111/j.1748-5827.1989.tb01469.x
Yeon, S.C., Lee, H.C., Chang, H.H. & Lee, H.J., 2005, ‘Sound signature for identification
of tracheal collapse and laryngeal paralysis in dogs’, Journal of Veterinary Medical
Science 67, 91–95. http://dx.doi.org/10.1292/jvms.67.91, PMid:15699602
Zikes, C. & McCarthy, T., 2012, ‘Bilateral ventriculocordectomy via ventral laryngotomy
for idiopathic laryngeal paralysis in 88 dogs’, Journal of the Amercian Animal
Hospital Association 48(4), 234–244. http://dx.doi.org/10.5326%2FJAAHA-
MS-5751
doi:10.4102/jsava.v84i1.909
3 CE
CREDITS CE Article 1

Laryngeal Paralysis in Dogs

❯❯ R
 alph P. Millard, DVM Abstract: Laryngeal paralysis is a common cause of upper airway obstruction in large-breed dogs.
❯❯ K
 aren M. Tobias, DVM, Although congenital forms have been reported, the disease is usually an acquired condition in older
MS, DACVS dogs. Clinical signs include voice change, inspiratory stridor, and dyspnea. Laryngeal paralysis is
 niversity of Tennessee
❯❯ U diagnosed by observing the absence of arytenoid abduction during laryngeal examination under a
light plane of anesthesia. The most common method of surgical treatment is unilateral arytenoid
lateralization. Most dogs experience significant improvement in respiration following surgery;
however, they have an increased risk of aspiration pneumonia for the remainder of their lives.

L
aryngeal paralysis is a well-recog- laryngeal paralysis displayed neurogenic
nized disease of large-breed dogs atrophy of the cranial tibial muscle and
that results in upper airway obstruc- axonal degeneration of the peroneal nerve
tion and dyspnea. The condition results in all cases, regardless of whether the
from dysfunction of the caudal laryngeal dogs had signs of peripheral neuropathy.8
nerves, which are the terminations of Within 2 years after diagnosis of laryn-
the recurrent laryngeal nerves. The cau- geal paralysis, clinical signs of general-
dal laryngeal nerves provide innervation ized lower motor neuron disease were
to all the muscles of the larynx except
the cricothyroideus muscle. Dysfunction FIGURE 1
of these nerves results in the loss of
arytenoid abduction by the cricoarytenoi-
deus dorsalis muscle and the inability to
actively constrict the glottis or relax the
At a Glance vocal folds1 (Figures 1 and 2).

Etiology Etiology
Page 212
Laryngeal paralysis can be congenital or
Signalment and Clinical acquired. A hereditary form has been
Signs described in Bouvier des Flandres, dal-
Page 213 matians, rottweilers, and Siberian huskies
Diagnosis and is usually reported in dogs younger
Page 213 than 1 year.2–5 Acquired laryngeal paraly-
Medical Management sis may result from trauma or iatrogenic
Page 216 injury to the recurrent laryngeal nerve
(e.g., during thyroidectomy) or compres-
Surgical Treatment
Page 217 sion of the recurrent laryngeal nerve by
a cranial mediastinal or cervical mass.6
More commonly, however, laryngeal paral-
ysis is classified as idiopathic in older
dogs. Although the underlying etiology is
Cranial view of a dissected canine
unknown, idiopathic laryngeal paralysis
larynx. (a) Corniculate process of arytenoid
is most likely part of a generalized periph- cartilage, (b) cuneiform process of arytenoid
eral neuropathy.7 In one recent study, cartilage, (c) epiglottis, (d) vocal fold, (e) laryn-
muscle and peripheral nerve biopsy sam- geal ventricles, (f) cricoid cartilage, (g) muscu-
ples obtained from 11 dogs with acquired lar process of arytenoid cartilage.

212 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com


present in all dogs in the study. 8 Although
laryngeal paralysis has been reported in dogs
with hypothyroidism, the association between
the two conditions is unknown.9,10 Myasthenia
gravis has also been suggested as a cause of
laryngeal paralysis in dogs.11
Signalment and Clinical Signs
Laryngeal paralysis is most commonly reported
in older, large-breed dogs, especially Labrador
retrievers.9,12–14 The average age at the time of
presentation is approximately 10 years.9,12,14
Males are affected more frequently than
females.12–14 Clinical signs progress as laryn-
geal dysfunction becomes more severe. Early
in the disease process, owners may notice a
voice change, inspiratory stridor, and exercise
intolerance. Owners may initially believe that
the dog’s reluctance to move is simply a sign
of aging. Dysphagia can also occur, possibly
in association with peripheral neuropathy.9,14
Owners may also report vomiting; however,
they may actually be seeing regurgitation from
concurrent esophageal disease or gagging and
retching from a soft palate that has elongated
as a result of inspiratory dyspnea. Once the
laryngeal muscles are paralyzed bilaterally,
dogs may develop severe dyspnea, cyanosis,
and syncope. Exercise, obesity, excitement,
and increased ambient temperature can exac-
erbate clinical signs, leading to an emergency
presentation.9 Affected dogs may develop
pneumonia or pulmonary edema, which can
contribute to respiratory distress. Inability
to constrict the glottis properly during swal-
lowing, regurgitation, or vomiting increases
the risk of aspiration. Pulmonary edema can
develop in cases of upper airway obstruction
as a result of changes in intrathoracic pressure
and hypoxia, which cause increased perme-
ability of alveolar capillary membranes.15,16
Diagnosis
If an affected dog is stable, it should undergo
a thorough physical examination. The thorax
should be auscultated for evidence of pneumo-
nia or pulmonary edema, such as harsh crack-
les, wheezes, or rales, and for cardiac murmurs
or arrhythmias. Arterial pulses should be pal-
pated for rate, rhythm, symmetry, and strength
to assess for cardiovascular abnormalities that
CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians®
FREE
Laryngeal Paralysis in Dogs CE
FIGURE 2
Lateral view of a dissected canine larynx. (a) Thyroid cartilage, (b) cricoid
cartilage, (c) hyoid apparatus, (d) epiglottis, (e) corniculate process of arytenoid
cartilage.
could contribute to exercise intolerance. A
complete neurologic examination should be
performed to evaluate for signs of polyneu-
ropathy, such as decreased postural reactions,
deficits in spinal reflexes, and cranial nerve
abnormalities.7
A rectal temperature should be obtained,
and all dogs should be evaluated for sys-
temic signs of heatstroke, such as petechial QuickNotes
hemorrhages associated with disseminated
intravascular coagulation, excessive panting, Acquired laryngeal
collapse, hyperemic mucous membranes, and paralysis may be
abnormalities in mentation, regardless of body associated with a
temperature at time of presentation.17,18 The generalized periph-
primary means of heat loss in dogs is evapo- eral neuropathy.
ration while panting. Dogs affected by acute
signs of laryngeal paralysis are more suscepti-
ble to hyperthermia due to a lack of heat dissi-
pation through an obstructed respiratory tract.
Heatstroke from sustained hyperthermia can
progress to multiorgan failure and death.17,18
If the body temperature is ≥106°F (41°C) or
systemic signs of heatstroke are evident, addi-
tional diagnostics (e.g., coagulation panels,
immediate evaluation of glucose and elec-
trolytes) and supportive treatment should be
instituted.
Complete blood count and serum biochem-
istry profile results are typically normal unless
concurrent diseases are present. In dogs with
213
FREE
CE Laryngeal Paralysis in Dogs
peripheral weakness, exercise intolerance, mega­
e­sophagus, or other signs of generalized poly­
neuropathy, free thyroxine and endogenous
thyroid-stimulating hormone concentrations are
measured to rule out hypothyroidism, and ace-
tylcholine receptor antibody titers are measured
to rule out myasthenia gravis.7,19 The association
of laryngeal paralysis with hypothyroidism or
myasthenia gravis is unclear, however, as medi-
cal treatment for either of these conditions is
unlikely to restore laryngeal nerve function.
Thoracic radiography is important for rul-
ing out other causes of dyspnea and exercise
intolerance and for determining whether con-
current conditions are present in dogs with
laryngeal paralysis. The lung fields should be
assessed for evidence of aspiration pneumonia
and noncardiogenic pulmonary edema, which
can occur with upper airway obstruction. Dogs
QuickNotes with laryngeal paralysis from polyneuropathy
or neuromuscular junction disease such as
Every dog sus- myasthenia gravis may develop megaesopha-
pected of having gus, which significantly increases the likeli-
laryngeal paralysis hood of aspiration pneumonia11,12 (Figure 3).
should undergo tho- A contrast esophagram with videofluoroscopy
racic radiography. may be required to make a definitive diagno-
sis of decreased esophageal motility.20 The risk
of aspiration largely outweighs the diagnostic
benefits of contrast esophagography; there-
fore, this procedure is not performed routinely
in dogs with laryngeal paralysis.
Laryngeal paralysis is most commonly
diagnosed with transoral laryngoscopy under
a light plane of anesthesia. Excessive admin-
istration of any anesthetic can inhibit laryn-
geal motion; however, some drugs may reduce
arytenoid abduction under a light plane of
anesthesia. In a comparison of seven different
anesthetic protocols,21 acepromazine plus thi-
opental, acepromazine plus propofol, and ket-
amine plus diazepam resulted in no laryngeal
motion in 67%, 50%, and 50% of normal dogs,
respectively. Thiopental and propofol as single
agents inhibit laryngeal motion less than these
drug combinations.21,22 However, compared
with propofol, thiopental as a single agent
results in significantly more arytenoid motion
during inspiration and is therefore preferred
for evaluation of laryngeal function.21,22 Often,
dogs receive acepromazine when they present
with anxiety and respiratory distress. In the
comparison study, laryngeal function was evi-
dent in all normal dogs that received acepro-
mazine and butorphanol sedation and were

FIGURE 3
Thoracic Radiographs.

A B

Thoracic radiographs of a dog with megaesophagus and aspiration

pneumonia. Note the borders of a dilated, air-filled esophagus (arrowheads)
and air bronchograms (arrows). (A) Ventrodorsal view. (B) Right lateral view.

214 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com

FREE
CE Laryngeal Paralysis in Dogs
Box 1
Unless the examiner is aware of the phase
Anesthetic Regimens for of respiration, it is easy to mistake paradoxical
Diagnosing Laryngeal movement of the larynx for active abduction.
Paralysis in Dogs21 Lack of arytenoid cartilage abduction during
inspiration narrows the rima glottidis, increas-
ing resistance to airflow. Rapid, forceful inspira-
Preoxygenate for 3 to 5 minutes before tion creates negative pressure within the larynx,
induction. which pulls the flaccid arytenoid cartilages
medially, worsening the obstruction.27 The car-
T hiopental (12–16 mg/kg IV to effect) tilages are forcefully separated by airflow as the
Propofol (4.5–7 mg/kg IV slowly to effect) animal exhales. Therefore, dogs with laryngeal
and doxapram (1 mg/kg IV) paralysis and paradoxical motion have inward
Acepromazine (0.2 mg/kg IM) and butor- movement of the arytenoid cartilages on inspi-
phanol (0.4 mg/kg IM) 20 minutes before
ration and outward, passive movement of the
mask induction with isoflurane
cartilages during expiration. Intubation may be
required in some patients with severe paradox-
ical motion and resultant hypoxia.23
examined under a light plane of anesthesia
induced by mask inhalation of isoflurane.21 In Medical Management
QuickNotes animals in which laryngeal function has been Dogs that present with acute cyanosis or in col-
depressed by sedatives and opioids, doxapram lapse require emergency treatment. Supplemen­
In dogs with
(1 mg/kg) can be administered intravenously tal oxygen should be provided to help alleviate
laryngeal paraly-
to stimulate respiration23 (Box 1). hypoxia. An intravenous catheter should be
sis, paradoxical Although a portable laryngoscope can be placed for administration of fluid and medica-
movement can be used to visualize the rima glottidis, retraction tions. Severely dyspneic or anxious dogs may
mistaken for active of the tongue and pressure on the epiglot- require sedation with acepromazine (0.005 to
arytenoid abduction tis with the laryngoscope blade may affect 0.02 mg/kg IV) and butorphanol (0.2 to 0.4 mg/
during laryngeal laryngeal function. Therefore, many clinicians kg IV) or other sedatives. If laryngeal edema is
examination. prefer to use a transoral video endoscope. suspected, an antiinflammatory dose of a gluco­
Laryngeal paralysis has also been diagnosed corticoid such as dexamethasone (0.1 to 0.5 mg/
with transnasal laryngoscopy and laryngeal kg) or prednisolone sodium succinate (0.5 to
ultrasound.24,25 1 mg/kg) can be administered intravenously.
If possible, blood oxygen saturation should Dogs that are significantly hyperthermic (≥106°F
be monitored with a pulse oximeter during [41°C]) are treated with sedatives, IV fluids, cool
laryngoscopy to ensure that the hemoglobin water baths, and fans. The rectal temperature
saturation remains ≥95%.26 Flow-by oxygen should be monitored continuously until it has
can be administered by attaching flexible tub- stabilized within a normal range and external
ing from an oxygen source to the blade of cooling has been discontinued. Dogs that are
the laryngoscope or to the insufflation port cyanotic, severely dyspneic, or hypoxic (SpO2
of the video endoscope to reduce the risk of <95%) despite supplemental oxygen therapy
hypoxia. During laryngeal examination, laryn- may require intubation and light anesthesia until
geal motion should be correlated with the laryngeal swelling resolves. If an intubation
phase of respiration. It is helpful to have an period of several hours or longer is expected,
assistant call out when each inspiration and a tracheostomy tube should be placed to avoid
VIDEO expiration occurs. In normal dogs, the rima exacerbation of laryngeal swelling from the
glottidis remains open at rest, closes slightly endotracheal tube and prolonged periods of
during expiration, and opens widely during anesthesia.28 It is possible for severe cases to
inspiration. Inability of the arytenoid carti- progress to respiratory muscle fatigue, which
To see videos of lages to abduct during inspiration is diagnostic may require mechanical ventilation.29 There is
normal and paralyzed
for laryngeal paralysis. In questionable cases, no reliable bedside measurement for detection
laryngeal abduction,
please visit
doxapram is administered intravenously.23 Res­ of respiratory muscle fatigue; the diagnosis is
CompendiumVet.com. piration is usually stimulated within 8 seconds based on changes in breathing patterns, such as
after administration. inward movement of the abdomen during inspi-

216 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com

 FREE
Laryngeal Paralysis in Dogs CE

ration, uncoordinated alterations between rib- FIGURE 4

cage and abdominal movements, and increased
PaCO2 on blood gas analysis.29
Dogs that have mild clinical signs or are
asymptomatic at rest may be managed con-
servatively by reducing stress, excitement, and
exposure to high ambient temperatures and
with weight loss as needed. Owners should
be informed that laryngeal paralysis is usually
progressive and that many dogs require surgery
as clinical signs become more severe or qual-
ity of life is affected.

Surgical Treatment
The goal of surgery is to enlarge the size of the
rima glottidis to decrease resistance to airflow
during inspiration. Surgical techniques include
unilateral arytenoid lateralization (UAL), partial
arytenoidectomy, vocal fold resection, castel- Dorsolateral view of a dissected canine larynx. (a) Muscular process of
arytenoid cartilage, (b) cricoid cartilage, (c) thyroid cartilage, (solid line) suture
lated laryngofissure, and muscle–nerve pedi-
placement for cricoarytenoid lateralization, (broken line) suture placement for
cle transposition. 30–32
Some dogs may require thyroarytenoid lateralization.
concurrent soft palate resection because pro-
longed negative airway pressure can increase tilage during inspiration33 (Figures 4 and 5).
soft palate length and thickness. Castellated Active abduction of the arytenoid with the
laryngofissure is rarely performed, and mus- suture is not required to reduce laryngeal air-
cle–nerve pedicle transposition has not been way resistance.34,35 If the soft palate is elongated,
evaluated in dogs with spontaneous laryngeal it is resected before recovery from anesthesia.
paralysis; therefore, these procedures are not Bilateral arytenoid lateralization increases the
described in this article. risk of postoperative complications and respira-
In animals undergoing vocal fold resec- tory-related death and is not recommended.11
tion for laryngeal paralysis, the vocal fold and Complications are reported in 10% to 28%
process are removed unilaterally or bilaterally. of dogs that undergo UAL (Box 2) and include QuickNotes
The procedure is often performed transorally aspiration pneumonia (8% to 33%), coughing
with scissors. If bilateral vocal cordectomy is and gagging (16%), suture failure or return of Administration of
performed, the ventral 1 to 2 mm of the vocal clinical signs (4% to 8%), gastric dilatation– doxapram during
fold should be left in place to reduce the risk volvulus (4%), respiratory distress (2% to 4%), laryngeal exami-
of scar formation and subsequent glottal steno- and sudden death (3%).12,14,36 Aspiration pneu- nation facilitates
sis. Partial arytenoidectomy involves unilateral monia may occur shortly after surgery or at differentiation of
resection of the corniculate process of the
laryngeal paraly-
arytenoid cartilage. This procedure can also be Box 2
performed through a transoral approach with
sis from drug-
cup biopsy forceps and may be combined with Complications of Unilateral induced laryngeal
a vocal fold resection. In one study, complica-
12
Arytenoid Lateralization dysfunction.
tions were reported in 40% of dogs undergo-
ing unilateral laryngectomy (arytenoidectomy,
Aspiration pneumonia
vocal cordectomy, or a combination of both)
Coughing/gagging
for treatment of laryngeal paralysis, and 30% of
Surgical repair failure
the dogs died from respiratory-related causes.
UAL is the most commonly performed pro-
Respiratory distress
cedure for laryngeal paralysis.12,14 With this Gastric dilatation–volvulus
technique, a suture is placed between the Seroma formation
arytenoid and cricoid or thyroid cartilages to Sudden death
prevent inward motion of the arytenoid car-

CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 217

FREE
CE Laryngeal Paralysis in Dogs
FIGURE 5
Lateral view of a dissected canine larynx. (a) Muscular process of
arytenoid cartilage, (b) cricoid cartilage, (c) cricothyroid articulation, (d) thyroid
cartilage retracted laterally, (e) articulation of thyroid cartilage and thyrohyoid
bone, (solid line) suture placement for cricoarytenoid lateralization.
QuickNotes
Aspiration pneu-
monia is the most
common complica-
tion after surgery for
laryngeal paralysis.
218 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
any time for the remainder of the dog’s life.
The use of metoclopramide reduces the risk of
perioperative aspiration pneumonia.36
Median survival times after UAL range from
1 to 5 years, with approximately 14% of dogs
dying from diseases related to the respiratory
tract.12,14 Factors associated with a higher rate
of complications or death include increasing
age, placement of a temporary tracheostomy
tube, and presence of concurrent respiratory
tract abnormalities, postoperative megaesoph-
References
1. Evans HE, Kitchell RL. Cranial nerves and cutaneous innervation of
the head. In: Evans HE, ed. Miller’s Anatomy of the Dog. Philadelphia:
WB Saunders; 1993:953-987.
2. Venker-van Haagen AJ, Bouw J, Hartman W. Hereditary trans-
mission of laryngeal paralysis in Bouviers. JAAHA 1981;17:75-76.
3. Braund KG, Shores A, Cochrane S, et al. Laryngeal paralysis-polyneu-
ropathy complex in young dalmatians. Am J Vet Res 1994; 55:534-542.
4. Mahony OM, Knowles KE, Braund KG, et al. Laryngeal paraly-
sis-polyneuropathy complex in young rottweilers. J Vet Intern Med
1998;12:330-337.
5. Polizopoulou ZS, Koutinas AF, Papadopoulos GC, et al. Juve-
nile laryngeal paralysis in three Siberian husky x Alaskan malamute
puppies. Vet Rec 2003;153:624-627.
6. Klein MK, Powers BE, Withrow SJ, et al. Treatment of thyroid
carcinoma in dogs by surgical resection alone: 20 cases (1981-
1989). JAVMA 1995;206:1007-1009.
7. Jeffery ND, Talbot CE, Smith PM, et al. Acquired idiopathic la-
ryngeal paralysis as a prominent feature of generalised neuromus-
cular disease in 39 dogs. Vet Rec 2006;158:17.
8. Thieman KM, Krahwinkel DJ, Shelton D, et al. Laryngeal paraly-
sis: part of a generalized polyneuropathy syndrome in older dogs.
Vet Surg 2007;36:E26.
9. Burbidge HM. A review of laryngeal paralysis in dogs. Br Vet J
1995;151:71-82.
agus, and neurologic disease.12 In one study,
five of six dogs that developed megaesopha-
gus in conjunction with aspiration pneumonia
died.12 Because polyneuropathy is suspected as
an underlying etiology for laryngeal paralysis,
affected dogs should be monitored frequently
for evidence of neuromuscular weakness
and esophageal dysfunction. The associa-
tion between temporary tracheostomy tube
placement and increased postoperative com-
plications should be interpreted with caution
because dogs that require tracheostomy tubes
are likely to be in critical condition. Clinicians
should not hesitate to place a tracheostomy tube
in animals with severe inspiratory dyspnea.
Despite complications, approximately 90%
of dogs have a reduction in respiratory signs
and improved exercise tolerance after UAL.
Most owners report an improvement in qual-
ity of life and are satisfied with their decision
to go to surgery.12,14
Conclusion
Laryngeal paralysis is a common cause of upper
airway obstruction in older, large-breed dogs
and is likely associated with a generalized poly-
neuropathy in most animals. Surgical therapy
is frequently indicated, and UAL is currently
the recommended treatment. Respiratory signs
significantly improve in most patients after sur-
gery; however, postoperative complication rates
can be high, and patients have a lifelong risk of
developing respiratory tract disease.
10. Jaggy A, Oliver JE, Ferguson DC, et al. Neurological manifestations
of hypothyroidism: a retrospective study of 29 dogs. J Vet Intern Med
1994;8:328-336.
11. Dewey CW, Bailey CS, Shelton GD, et al. Clinical forms of acquired
myasthenia gravis in dogs: 25 cases (1988-1995). J Vet Intern Med
1997;11:50-57.
12. MacPhail CM, Monnet E. Outcome of and postoperative compli-
cations in dogs undergoing surgical treatment of laryngeal paraly-
sis: 140 cases (1985-1998). JAVMA 2001;218:1949-1956.
13. Snelling SR, Edwards GA. A retrospective study of unilateral
arytenoid lateralisation in the treatment of laryngeal paralysis in 100
dogs (1992-2000). Aust Vet J 2003;81:464-468.
14. Hammel SP, Hottinger HA, Novo RE. Postoperative results of uni-
lateral arytenoid lateralization for treatment of idiopathic laryngeal pa-
ralysis in dogs: 39 cases (1996-2002). JAVMA 2006;228:1215-1220.
15. Algren JT, Price RD, Buchino JJ, et al. Pulmonary edema asso-
ciated with upper airway obstruction in dogs. Pediatr Emerg Care
1993;9:332-337.
16. John PJ, Mahashur AA. Pulmonary oedema associated with air-
way obstruction. Can J Anaesth 1991;38:139-140.
17. Bruchim Y, Klement E, Saragusty J, et al. Heat stroke in dogs: a ret-
rospective study of 54 cases (1999-2004) and analysis of risk factors
for death. J Vet Intern Med 2006;20:38-46.
18. Flournoy WS, Macintire DK, Wohl JS. Heatstroke in dogs: clini-
 FREE
Laryngeal Paralysis in Dogs CE

cal signs, treatment, prognosis, and prevention. Compend Contin
Educ Pract Vet 2003;25:422-431.
19. Shelton GD. Myasthenia gravis and disorders of neuromuscular trans-
mission. Vet Clin North Am Small Anim Pract 2002;32:189-206, vii.
20. Washabau RJ, Hall JA. Diagnosis and management of gastroin-
testinal motility disorders in dogs and cats. Compend Contin Educ
Pract Vet 1997;19:721-737.
21. Jackson AM, Tobias K, Long C, et al. Effects of various anes-
thetic agents on laryngeal motion during laryngoscopy in normal
dogs. Vet Surg 2004;33:102-106.
22. Gross ME, Dodam JR, Pope ER, et al. A comparison of thiopen-
tal, propofol, and diazepam-ketamine anesthesia for evaluation of
laryngeal function in dogs premedicated with butorphanol-glycopy-
rrolate. JAAHA 2002;38:503-506.
23. Tobias KM, Jackson AM, Harvey RC. Effects of doxapram HCl
on laryngeal function of normal dogs and dogs with naturally oc-
curring laryngeal paralysis. Vet Anaesth Analg 2004;31:258-263.
24. Radlinsky MG, Mason DE, Hodgson D. Transnasal laryngoscopy for
the diagnosis of laryngeal paralysis in dogs. JAAHA 2004;40:211-215.
25. Rudorf H, Barr FJ, Lane JG. The role of ultrasound in the assessment
of laryngeal paralysis in the dog. Vet Radiol Ultrasound 2001;42:338-343.
26. Proulx J. Respiratory monitoring: arterial blood gas analysis,
pulse oximetry, and end-tidal carbon dioxide analysis. Clin Tech
Small Anim Pract 1999;14:227-230.
27. Smith MM. Diagnosing laryngeal paralysis. JAAHA 2000;36:383-
384.
28. Bishop MJ, Hibbard AJ, Fink BR, et al. Laryngeal injury in a
dog model of prolonged endotracheal intubation. Anesthesiology
1985;62:770-773.
29. Barton L. Respiratory muscle fatigue. Vet Clin North Am Small
Anim Pract 2002;32:1059-1071, vi.
30. Greenfield CL, Walshaw R, Kumar K, et al. Neuromuscular pedicle graft
for restoration of arytenoid abductor function in dogs with experimentally
induced laryngeal hemiplegia. Am J Vet Res 1988;49:1360-1366.
31. Toth A, Szucs A, Harasztosi C, et al. Intrinsic laryngeal muscle
reinnervation with nerve-muscle pedicle. Otolaryngol Head Neck
Surg 2005;132:701-706.
32. Fulton IC, Stick JA, Derksen FJ. Laryngeal reinnervation in the
horse. Vet Clin North Am Equine Pract 2003;19:189-208, viii.
33. Mathews KG, Roe S, Stebbins M, et al. Biomechanical evalu-
ation of suture pullout from canine arytenoid cartilages: effects of
hole diameter, suture configuration, suture size, and distraction
rate. Vet Surg 2004;33:191-199.
34. Bureau S, Monnet E. Effects of suture tension and surgical ap-
proach during unilateral arytenoid lateralization on the rima glottidis
in the canine larynx. Vet Surg 2002;31:589-595.
35. Greenberg MJ, Bureau S, Monnet E. Effects of suture tension
during unilateral cricoarytenoid lateralization on canine laryngeal
resistance in vitro. Vet Surg 2007;36:526-532.
36. Greenberg MJ, Reems MR, Monnet E. Use of perioperative me-
toclopramide in dogs undergoing surgical treatment of laryngeal
paralysis: 43 cases (1999-2006). Vet Surg 2007;36:E11.

3 CE
CREDITS CE Test 1 This article qualifies for 3 contact hours of continuing education credit from the Auburn University College of Veterinary
Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumVet.com. Those who wish to apply this
credit to fulfill state relicensure requirements should consult their respective state authorities regarding the applicability of this program.

1. The most common cause of acquired 5. Which anesthetic protocol decreases 8. Which factor is associated with a higher
laryngeal paralysis is laryngeal function in at least 50% of rate of complications or death after UAL
a. hypothyroidism. normal dogs? in dogs with laryngeal paralysis?
b. myasthenia gravis. a. acepromazine/thiopental a. young age
c. trauma. b. acepromazine/propofol b. obesity
d. idiopathic. c. ketamine/diazepam c. the need to place a temporary
d. all of the above tracheostomy tube
2. The muscle responsible for abduction d. perioperative metoclopramide
of the arytenoid cartilages during 6. Regarding partial laryngectomy, which
inspiration is the ___________ muscle. statement is true? 9. Which statement is true?
a. cricoarytenoideus dorsalis a. In dogs undergoing bilateral vocal cor- a. Shortening an elongated soft palate
b. cricoarytenoideus lateralis dectomy, the entire vocal fold should be increases the risk of postoperative aspi-
c. thyropharyngeus removed. ration after arytenoid lateralization.
d. arytenoideus transversus b. Partial arytenoidectomy is performed b. During UAL, the arytenoid cartilage
by removing the corniculate process of should be maximally abducted with
3. Laryngeal paralysis has been identified the arytenoid cartilage. sutures to enlarge the glottic opening.
as a congenital condition in c. Complications are reported in 10% of c. Bilateral arytenoid lateralization
a. Labrador retrievers. dogs undergoing unilateral partial laryn- increases the risk of postoperative
b. Great Danes. gectomy for laryngeal paralysis. complications and respiratory-related
c. Afghan hounds. d. Approximately 5% of dogs undergoing death.
d. Bouvier des Flandres. unilateral partial laryngectomy die from d. The risk of aspiration pneumonia signifi-
respiratory-related diseases. cantly decreases 1 year after UAL.
4. Which is an early sign of laryngeal
paralysis? 7. The most common complication after 10. Approximately ___________ of dogs expe-
a. syncope unilateral arytenoid lateralization is rience improvement in upper airway
b. cardiac murmur a. respiratory distress. resistance and exercise tolerance fol-
c. voice change b. aspiration pneumonia. lowing arytenoid lateralization.
d. cyanosis c. seroma formation. a. 30% c. 75%
d. suture failure. b. 50% d. 90%

CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 219

13.2.2013 EN Official Journal of the European Union L 42/1

II
(Non-legislative acts)

REGULATIONS

COMMISSION REGULATION (EU) No 122/2013

of 12 February 2013
amending Regulation (EC) No 1950/2006 establishing, in accordance with Directive 2001/82/EC of
the European Parliament and of the Council on the Community code relating to veterinary
medicinal products, a list of substances essential for the treatment of equidae
(Text with EEA relevance)

THE EUROPEAN COMMISSION, modes of actions, different pharmacokinetic or phar­

Having regard to the Treaty on the Functioning of the European
Union,
Having regard to Directive 2001/82/EC of the European
Parliament and of the Council of 6 November 2001 on the
Community code relating to veterinary medicinal products (1),
and in particular Article 10(3) thereof,
Whereas:
(1) Commission Regulation (EC) No 1950/2006 (2) estab­
lished a list of substances essential for the treatment of
equidae which, by way of derogation from Article 11 of
Directive 2001/82/EC, may be administered to equidae
intended for slaughter for human consumption subject to
a withdrawal period of not less than six months.
(2) Regulation (EC) No 470/2009 of the European
Parliament and of the Council of 6 May 2009 laying
down Community procedures for the establishment of
residue limits of pharmacologically active substances in
foodstuffs of animal origin (3) amended Article 10(3) of
Directive 2001/82/EC in order to include in the list of
substances referred to in that Article substances which
bring added clinical benefit compared to other treatment
options available for equidae, hereinafter ‘substances
bringing added clinical benefit’, in addition to essential
substances.
macodynamic profiles, different lengths of treatment or
different routes of administration.
(4) Substances listed in the Annex to Commission Regu­
lation (EU) No 37/2010 of 22 December 2009 on phar­
macologically active substances and their classification
regarding maximum residue limits in foodstuffs of
animal origin (4) should not appear on the list of
essential substances and substances bringing added
clinical benefit. Therefore, it is necessary to amend the
list in the Annex to Regulation (EC) No 1950/2006 to
remove from that list any substances listed in Regulation
(EU) No 37/2010.
(5) It is also appropriate to remove from the list in the
Annex to Regulation (EC) No 1950/2006 several
substances identified as alternatives to the substances
listed, which are not available for the treatment of
horses because they are not listed as ‘essential substances’
or ‘substances bringing added clinical benefit’ under
Regulation (EC) No 1950/2006 nor listed in the Annex
to Regulation (EU) No 37/2010.
(6) Due to changes in Union legislation since the adoption
of Regulation (EC) No 1950/2006, the references in that
Regulation to the relevant legislation on control mech­
anisms for equidae and on maximum residue limits
should be updated.

(3) A substance should only be included in the list as a
‘substance bringing added clinical benefit’ where it
provides a clinically relevant advantage based on
improved efficacy or safety or a major contribution to
treatment. This may be the result, inter alia, of different
(1) OJ L 311, 28.11.2001, p. 1.
(2) OJ L 367, 22.12.2006, p. 33.
(3) OJ L 152, 16.6.2009, p. 11.
(7) The amended list set out in the Annex to this Regulation
has been subject to a scientific evaluation carried out by
the Committee for Veterinary Medicinal Products of the
European Medicines Agency established by Regulation
(EC) No 726/2004 of the European Parliament and of
the Council (5).
(4) OJ L 15, 20.1.2010, p. 1.
(5) OJ L 136, 30.4.2004, p. 1.
L 42/2 EN Official Journal of the European Union
(8) Regulation (EC) No 1950/2006 should be amended
accordingly.
(9) The measures provided for in this Regulation are in
accordance with the opinion of the Standing
Committee on Veterinary Medicinal Products,
HAS ADOPTED THIS REGULATION:
Article 1
Regulation (EC) No 1950/2006 is amended as follows:
(1) the title of Regulation (EC) No 1950/2006 is replaced by
the following:
‘Commission Regulation (EC) No 1950/2006 of
13 December 2006 establishing, in accordance with
Directive 2001/82/EC of the European Parliament and
of the Council on the Community code relating to
veterinary medicinal products, a list of substances
essential for the treatment of equidae and of substances
bringing added clinical benefit’;
(2) Article 1 is replaced by the following:
‘Article 1
The list of substances essential for the treatment of equidae,
hereinafter “essential substances”, as well as of substances
which bring added clinical benefit compared to other
treatment options available for equidae, hereinafter “sub­
stances bringing added clinical benefit”, applicable by way
of derogation from Article 11 of Directive 2001/82/EC, is
set out in the Annex to this Regulation.’;
(3) in Article 2, the second subparagraph is replaced by the
following:
‘Substances bringing added clinical benefit may be used, for
the specific disease conditions, treatment needs or
zootechnical purposes specified in the Annex, where they
provide a clinically relevant advantage based on improved
efficacy or safety or a major contribution to treatment
compared to medicinal products authorised for equidae or
referred to in Article 11 of Directive 2001/82/EC.
This Regulation shall be binding in its entirety and directly applicable in all Member States.
Done at Brussels, 12 February 2013.
13.2.2013
For the purposes of the first and second subparagraphs, the
alternatives listed in the Annex shall be considered.’;
(4) Articles 3 and 4 are replaced by the following:
‘Article 3
1. Essential substances and substances bringing added
clinical benefit shall be used only in accordance with
Article 10(1) of Directive 2001/82/EC.
2. The details of a treatment with essential substances
shall be recorded in accordance with the instructions laid
down in Section IX of the identification document for
equidae set out in Commission Regulation (EC) No
504/2008 (*).
Article 4
Any substance that is entered in one of the lists in the
Annex to Commission Regulation (EU) No 37/2010 (**),
or the use of which for equidae is prohibited by Union
legislation, shall no longer be used for the purposes of
this Regulation.
___________
(*) OJ L 149, 7.6.2008, p. 3.
(**) OJ L 15, 20.1.2010, p. 1.’;
(5) in Article 5, paragraph 2 is replaced by the following:
‘2. Where Member States or veterinary professional
associations request the Commission to amend the list set
out in the Annex, they shall duly substantiate their request
and include any relevant scientific data available.’;
(6) the Annex to Regulation (EC) No 1950/2006 is replaced by
the Annex to this Regulation.
Article 2
This Regulation shall enter into force on the third day following
that of its publication in the Official Journal of the European
Union.
For the Commission
The President
José Manuel BARROSO
13.2.2013 EN Official Journal of the European Union L 42/3

ANNEX

‘ANNEX

List of substances essential for the treatment of equidae and substances bringing added clinical benefit compared
to other treatment options available for equidae

The withdrawal period for each of the substances on the following list shall be six months.

Indication Active substance Justification and explanation of use

Anaesthetics, analgesics and substances used in association with anaesthesia

Sedation and premedication
(and antagonism)
Acepromazine Purpose: premedication prior to general anaesthesia, mild
sedation.
Identification of alternatives: detomidine, romifidine,
xylazine, diazepam, midazolam.
Discussion of the specific advantages: acepromazine has
consistently been shown to reduce risk of anaesthetic
death. Mode of action (on limbic system) and unique
quality of sedation cannot be produced by the alpha-2
agonist sedatives (detomidine, romifidine and xylazine) or
the benzodiazepines (diazepam, midazolam).

Atipamezole Purpose: α-2 adrenoceptor antagonist used for reversal of

α-2 agonists.
Identification of alternatives: none identified.
Discussion of the specific advantages: only treatment for
hypersensitive individual and overdose. Emergency
medicine. Specifically used in cases of respiratory
depression.

Diazepam Purpose: premedication and induction of anaesthesia. Mild

(benzodiazepine) tranquilisation with minimal cardiov­
ascular and respiratory side effects. Anti-convulsant,
essential for treatment of seizures.
Identification of alternatives: acepromazine, detomidine,
romifidine, xylazine, midazolam, primidone, phenytoin.
Discussion of the specific advantages: in modern medicinal
standards an essential component of anaesthetic induction
protocols with very considerable equine experience. Used
with ketamine for induction of anaesthesia, producing
essential relaxation that allows smooth induction and intu­
bation. Mode of action (acts at GABA receptor) and unique
tranquilisation without cardiorespiratory depression cannot
be produced by the α-2 agonist sedatives (detomidine,
romifidine and xylazine) or acepromazine.

Flumazenil Purpose: intravenous reversal agent for benzodiazepines.

Reversal of benzodiazepine effect during recovery from
Total Intravenous Anaesthesia (TIVA) techniques.
Identification of alternatives: sarmazenil.
Discussion of the specific advantages: different mode of
action from sarmazenil providing additional means of
benzodiazepine reversal at the end of TIVA techniques.
Sarmazenil is partial inverse agonist of benzodiazepine
receptors whereas flumazenil is an antagonist competitively
inhibiting the benzodiazepine binding site at the GABA
receptor.

Midazolam Purpose: premedication and induction of anaesthesia. Mild

(benzodiazepine) tranquilisation with minimal cardiov­
ascular and respiratory side effects. Anti-convulsant, for
treatment of seizures, particularly adult horses with tetanus.
L 42/4 EN Official Journal of the European Union 13.2.2013

Indication Active substance Justification and explanation of use

Identification of alternatives: acepromazine, detomidine,

romifidine, xylazine, diazepam, primidone, phenytoin.
Discussion of the specific advantages: similar to diazepam
but water soluble, thus suitable for intravenous injection
and essential for intravenous infusion in combination with
anaesthetics. Shorter acting than diazepam. More suitable
than diazepam for foals.
Anti-convulsant, for treatment of seizures, particularly adult
horses with tetanus – better than diazepam for use over
several days due to water solubility.
Used with ketamine for induction of anaesthesia, producing
essential relaxation that allows smooth induction and intu­
bation.
Mode of action (acts at GABA receptor) and unique tran­
quilisation without cardiorespiratory depression cannot be
produced by the α-2 agonist sedatives (detomidine,
romifidine and xylazine) or acepromazine.

Naloxone Purpose: opioid-antidote, emergency medicine.

Identification of alternatives: none identified.
Discussion of the specific advantages: no alternatives avail­
able.

Propofol Purpose: intravenous anaesthetic. Induction of anaesthesia

in foals.
Identification of alternatives: sevoflurane or isoflurane.
Discussion of the specific advantages: rapidly cleared
injectable anaesthetic. Recent reports demonstrate vast
improvement in cardiovascular stability and quality of
recovery over inhalation anaesthesia.

Sarmazenil Purpose: benzodiazepine antagonist.

Identification of alternatives: flumazenil.
Discussion of the specific advantages: clean reversal of
benzodiazepine sedation required after infusion during
total intravenous anaesthesia. Widest clinical experience
with sarmazenil compared to other potential candidates
for essential substances.

Tiletamine Purpose: dissociative anaesthetic similar to ketamine,

especially used for field anaesthesia. Used in combination
with zolazepam.
Identification of alternatives: ketamine.
Discussion of the specific advantages: the use in
combination with zolazepam is essential in cases when
there is no access to inhalation anaesthesia such as for
field anaesthesia. Combination is also essential where
anaesthesia with ketamine combinations is too short.
Typical applications are castrations, laryngotomies, peri­
osteal stripping, cyst or lump excisions, repair of facial
fractures, cast applications and umbilical hernia repairs.

Zolazepam Purpose: benzodiazepine tranquilisation especially used for

field anaesthesia in combination with tiletamine.
Identification of alternatives: diazepam or midazolam.
Discussion of the specific advantages: benzodiazepine tran­
quiliser, which is longer acting than either diazepam or
13.2.2013 EN Official Journal of the European Union L 42/5

Indication Active substance Justification and explanation of use

midazolam. The use with tiletamine is essential in cases

when there is no access to inhalation anaesthesia such as
for field anaesthesia. Combination is essential where anaes­
thesia with ketamine combinations is too short. Typical
applications are castrations, laryngotomies, periosteal
stripping, cyst or lump excisions, repair of facial fractures,
cast applications and umbilical hernia repairs.

Hypotension or respiratory Dobutamine Purpose: treatment of hypotension during anaesthesia.

stimulation during
anaesthesia Identification of alternatives: dopamine.
Discussion of the specific advantages: positive inotrope
therapy, probably more used than dopamine but pref­
erences vary. Horses usually develop hypotension during
anaesthesia, and maintenance of normal blood pressure
has been shown to reduce the incidence of serious post-
operative rhabdomyolysis. Dobutamine is invaluable during
volatile anaesthesia in horses.

Dopamine Purpose: treatment of hypotension during anaesthesia.

Identification of alternatives: dobutamine.
Discussion of the specific advantages: dopamine is required
in horses that do not respond to dobutamine. In foals
dopamine is used in preference to dobutamine.
Additionally required for treatment of intraoperative brady­
dysrhythmias that are resistant to atropine.

Ephedrine Purpose: treatment of hypotension during anaesthesia.

Identification of alternatives: dopamine, dobutamine.
Discussion of the specific advantages: required where
dopamine and dobutamine are ineffective. A unique
sympathomimetic agent, which is structurally similar to
adrenaline. It is impossible to use the action of catecho­
lamines on specific receptors in the body to the benefit of
equine patients without recourse to the use of a number of
catecholamines, each active at a different receptor profile.
Hence ephedrine, which causes noradrenaline release at the
nerve endings, thereby increasing cardiac contractility and
obtunding hypotension, is used when dobutamine and
dopamine are ineffective. Ephedrine lasts minutes to
hours and is effective after a single intravenous injection,
whereas dobutamine and dopamine last only a few seconds
or minutes and must be given by infusion.

Glycopyrrolate Purpose: prevention of bradycardia. Anticholinergic. Anti­

cholinergics are fundamental treatment for prevention of
parasympathetic effects such as bradycardia and are routine
components of eye and airway surgery.
Identification of alternatives: atropine.
Discussion of the specific advantages: glycopyrrolate has a
limited central effect and is more suitable in conscious
horses (before and after anaesthesia) than atropine.

Noradrenaline Purpose: cardiovascular failure. Infusion for the treatment

(norepinephrine) of cardiovascular failure in foals.
Identification of alternatives: none identified.
Discussion of the specific advantages: the animal’s catecho­
lamine receptor profile responds precisely to medicines
acting at different sites. Hence a range of catecholamines
acting more or less exclusively on different types of
adrenergic receptors is used to produce a precise effect.
L 42/6 EN Official Journal of the European Union 13.2.2013

Indication Active substance Justification and explanation of use

Noradrenaline acts primarily on alpha-1 receptors to vaso­

constrict arterioles, thereby increasing blood pressure and
maintaining central circulation. In foals, noradrenaline is
commonly the only catecholamine effective in treatment
of hypotension.

Analgesia Buprenorphine Purpose: analgesia, used with sedatives for restraint.

Identification of alternatives: butorphanol, fentanyl,
morphine and pethidine.
Discussion of the specific advantages: partial μ-agonist
opioid analgesic. μ-receptor activity produces better
analgesia than κ-agonist opioids such as butorphanol.
Long-acting analgesic. Due to partial agonist characteristic,
has limited addictive and respiratory depressant properties.
Long and short-acting opioids have different indications,
hence the need for more than one alternative substances
as choice.

Fentanyl Purpose: analgesia.

Identification of alternatives: butorphanol, buprenorphine,
morphine and pethidine.
Discussion of the specific advantages: μ-agonist opioid, μ-
receptor activity produces better analgesia than κ-agonist
opioids such as butorphanol. Very short acting due to
rapid metabolism and excretion. Fentanyl is the only
opioid used in horses that is suitable for infusion and
skin patch administration. Highly effective for pain
management.

Morphine Purpose: analgesia.

Identification of alternatives: butorphanol, buprenorphine,
pethidine and fentanyl.
Discussion of the specific advantages: full μ-agonist opioid
analgesic. μ-receptor activity produces the best analgesia.
Used with sedatives for restraint, used for epidural anaes­
thesia. Mid duration analgesic. Morphine is the μ-opioid
agonist with the best solubility characteristics for epidural
administration. It provides long-acting analgesia with few
systemic effects by this route. This technique is widely used
in modern veterinary medicine for treating severe peri­
operative and chronic pain.

Pethidine Purpose: analgesia.

Identification of alternatives: butorphanol, buprenorphine,
morphine and fentanyl.
Discussion of the specific advantages: a μ-agonist opioid
analgesic about 10 times less potent than morphine.
Short-acting opioid that has been proven to be effective
to treat spasmodic colic in horses. Only opioid with spas­
molytic properties. More sedation and less potential for
excitement than other opioids in horses.

Muscle relaxants and Atracurium Purpose: muscle relaxation during anaesthesia.

associated substances
Identification of alternatives: guaifenesin.
Discussion of the specific advantages: non-depolarising
neuromuscular blocking agent. Neuromuscular blocking
agents are used in particular for eye and deep abdominal
surgery. Edrophonium is required for reversal. Atracurium
and edrophonium have the most extensive clinical support
data.
13.2.2013 EN Official Journal of the European Union L 42/7

Indication Active substance Justification and explanation of use

Edrophonium Purpose: reversal of atracurium muscle relaxation.

Identification of alternatives: none identified.
Discussion of the specific advantages: cholinesterase
inhibitor, essential for reversal of neuromuscular
blockade. Edrophonium has least side effects of the choli­
nesterase inhibitors in horses.

Guaifenesin Purpose: muscle relaxation during anaesthesia.

Identification of alternatives: atracurium.
Discussion of the specific advantages: essential alternative
to α-2/ketamine regimens in horses where α-2 agents and
ketamine are contraindicated such as in horses not
responding to these agents or horses having shown
adverse effects during a previous administration. Invaluable
in combination with ketamine and α-2 agents for
remarkably safe field anaesthesia for which no effective
alternative intravenous techniques have been developed.

Inhalation anaesthetics Sevoflurane Purpose: inhalation anaesthesia for horses with limb
fractures and other orthopaedic injuries and mask
induction of anaesthesia in foals.
Identification of alternatives: isoflurane.
Discussion of the specific advantages: sevoflurane is a
volatile anaesthetic with minor metabolism and fast
excretion. While there is an MRL for isoflurane in the
EU, isoflurane is not suitable for all equine anaesthetic
cases due to its recovery characteristics where excitement
may lead to the horse breaking a leg. Sevoflurane is
essential in certain equine surgeries where a smooth
recovery is vital, as it has been shown to produce a
smoother, more controlled recovery in horses. It is
therefore selected in preference to isoflurane for horses
with limb fractures and other orthopaedic injuries.
Furthermore sevoflurane is essential for mask induction
of anaesthesia in foals as it is completely non-irritant as
opposed to isoflurane, which is irritant and therefore
causes coughing and breath holding.

Local anaesthetics Bupivacaine Purpose: local anaesthesia.

Identification of alternatives: lidocaine.
Discussion of the specific advantages: long-acting local
anaesthetic. Long duration of action required for peri­
operative analgesia and treatment of chronic severe pain
such as laminitis. Bupivacaine is a longer-acting local
anaesthetic than the commonly used lidocaine. Lidocaine
alone gives approximately one hour of local anaesthesia.
Addition of adrenaline may prolong the effect to two
hours, but runs the risk of cutting the local blood
supply, and this combination therefore is unsuitable in a
number of conditions. Bupivacaine provides four to six
hours of local anaesthesia and is therefore much better
suited to post-operative analgesia and for management of
laminitis because a single injection is often sufficient; this is
essential on welfare grounds than repeated hourly lidocaine
injections. Shorter acting local anaesthetics are therefore
not suitable for the above as they require frequent repeat
injections with the attendant increased risk of adverse
reactions and unacceptability for animal welfare reasons.

Oxybuprocaine Purpose: local anaesthesia for use in eyes.

Identification of alternatives: none identified.
L 42/8 EN Official Journal of the European Union 13.2.2013

Indication Active substance Justification and explanation of use

Discussion of the specific advantages: widest clinical

experience with oxybuprocaine compared to other
potential candidates for essential substances.

Prilocaine Purpose: local anaesthesia prior to intravenous catheteri­

sation.
Identification of alternatives: none identified.
Discussion of the specific advantages: in specific prep­
arations (eutectic mixture of local anaesthetics) for topical
application to skin where it is absorbed intradermally in 40
min. Used to facilitate intravenous catheterisation,
especially in foals.

Anti-inflammatory substances

Corticosteroids Triamcinolone acetonide Purpose: intra-articular medication for degenerative joint

disease and osteoarthritis.
Identification of alternatives: methylprednisolone.
Discussion of the specific advantages: different cellular and
biosynthetic effects from the alternative corticosteroid
intra-articular medication methylprednisolone; triamci­
nolone is chondroprotective and promotes cartilage
repair. More effective than systemic treatments (NSAIDs
and chondroitin sulphate), and other (non-corticosteroid)
intra-articular treatments for control of joint inflammation,
pain and lameness in acute and chronic joint disease,
especially degenerative joint disease and osteoarthritis.
Only effective non-surgical treatment for subchondral
bone cysts.

Flumethasone Purpose: short-term systemic corticosteroid therapy

including shock, anti-inflammatory and anti-allergy
therapy.
Identification of alternatives: dexamethasone, prednisolone.
Discussion of the specific advantages: different clinical
effects from alternatives with more rapid onset, longer
duration and greater efficacy. Different mode of action
from alternatives (no appreciable mineralocorticoid activ­
ity).

Anti-endotoxins Pentoxifylline Purpose: systemic and oral treatment for endotoxaemia.

Laminitis.
Identification of alternatives: flunixin, acepromazine.
Discussion of the specific advantages:
Endotoxaemia: different mode of action (methylated
xanthine derivative phosphodiesterase inhibitor) and
different clinical effects to alternative (flunixin). Decreases
endotoxin-mediated release of pro-inflammatory cytokines
and leukotrienes from macrophages and neutrophils,
reduces systemic response to endotoxins.
Laminitis: different mode of action of improving blood
flow to the digit than alternative (acepromazine); reduces
blood viscosity and improves blood flow to the digit.

Polymyxin B Purpose: systemic treatment for endotoxaemia associated

with severe colic and other gastrointestinal diseases.
Identification of alternatives: flunixin, bismuth subsalicylate.
Discussion of the specific advantages: different mode of
action (endotoxin binding agent) to systemic alternative
(flunixin), acting earlier in the endotoxin-induced cascade.
Different mechanism of binding, different route of adminis­
tration and different site of action to oral alternative
bismuth. Aids in prevention of initiation of inflammatory
cascade induced by binding endotoxin and preventing
binding to Toll-like receptors.
13.2.2013 EN Official Journal of the European Union L 42/9

Indication Active substance Justification and explanation of use

Cardiovascular medicines

Amiodarone Purpose: anti-dysrhythmic. Systemic and oral treatment of

atrial fibrillation, supraventricular and ventricular tachyc­
ardias.
Identification of alternatives: quinidine sulphate, procain­
amide, propranolol.
Discussion of the specific advantages: different mode of
action to alternatives (class III anti-dysrhythmic). New
evidence that amiodarone is effective and safe in atrial
fibrillation and better than alternative quinidine sulphate;
effective for different types of arrhythmias including
ventricular arrhythmias.

Allopurinol Purpose: treatment of neonatal ischaemia-reperfusion

injury.
Identification of alternatives: vitamin E.
Discussion of the specific advantages: different mode of
action to alternative for reperfusion injury; allopurinol is
a xanthine oxidase inhibitor inhibiting free radical
production during reperfusion following ischaemia.

Vasopressin Purpose: treatment of circulatory collapse in foals and

adults.
Identification of alternatives: dopamine/dobutamine
Epinephrine.
Discussion of the specific advantages: specific agonist
acting via V1 receptors. Has a different mode of action
to the other authorized substances which regulate blood
pressure: epinephrine (an adrenergic receptor agonist) and
dopamine/dobutamine (D1-5 receptors regulating cardiac
output and blood vessel tone). Used in situations when
dopamine/dobutamine and epinephrine have been unsuc­
cessful and an alternative pharmacological approach is
needed.

Digoxin Purpose: treatment of heart failure.

Identification of alternatives: none identified.
Discussion of the specific advantages: additionally digoxin
is the only treatment for the side effects of quinidine treat­
ment.

Quinidine sulfate and Purpose: treatment of cardiac arrhythmias.

quinidine gluconate
Identification of alternatives: procainamide, propranolol.
Discussion of the specific advantages: anti-dysrhythmic
agent. Use is rare but important therapeutic choice,
different mode of action necessary for different types of
arrhythmias. Treatment of choice for atrial fibrillation.

Procainamide Purpose: treatment of cardiac arrhythmias.

Identification of alternatives: quinidine sulfate and
quinidine gluconate, propranolol.
Discussion of the specific advantages: anti-dysrhythmic
agent. Use is rare but important therapeutic choice,
different mode of action necessary for different types of
arrhythmias.

Propranolol Purpose: treatment of cardiac arrhythmias.

Identification of alternatives: quinidine sulfate and
quinidine gluconate, procainamide.
Discussion of the specific advantages: anti-hypertensive,
which is used because it also exerts some anti-arrhythmic
L 42/10 EN Official Journal of the European Union 13.2.2013

Indication Active substance Justification and explanation of use

activity. Use is rare but important therapeutic choice. Due

to the different pathophysiology of arrhythymias it is
essential to have a variety of different acting medicines in
order to be able to treat the specific condition. Use of these
medicines consists usually of a single treatment to convert
back to normal rhythm, which may have to be repeated on
only rare occasions.

Convulsions

Phenytoin Purpose: anti-convulsant therapy in foals. Treatment of

rhabdomyolysis. Treatment of stringhalt.
Identification of alternatives: diazepam, primidone,
dantrolene sodium (for rhabdomyolysis).
Discussion of the specific advantages: essential anti-
convulsant in foals. Phenytoin is generally added to the
treatment of seizure control if primidone/phenobarbital
does not control the seizures. Phenytoin is a calcium
channel-blocking agent and useful for the treatment of
recurrent forms of rhabdomyolysis.

Primidone Purpose: anti-convulsant therapy in foals.

Identification of alternatives: diazepam, phenytoin.
Discussion of the specific advantages: primidone is
indicated as follow-on from diazepam therapy or as an
alternative.

Gastrointestinal agents

Bethanechol Purpose: treatment of ileus, treatment of gastroduodenal

stricture in foals, treatment of recurrent small colon
impactions in adults.
Identification of alternatives: metoclopramide,
erythromycin.
Discussion of the specific advantages: betanechol is a
muscarinic cholinergic agonist that stimulates acetylcholine
receptors on gastrointestinal smooth muscles, causing them
to contract. It has been shown to increase the rate of
gastric and caecal emptying. Both betanechol and metoclo­
pramide have been shown to be beneficial in the treatment
of post-operative ileus.

Codeine Purpose: diarrhoea treatment.

Identification of alternatives: bismuth subsalicylate.
Discussion of the specific advantages: different mode of
action to bismuth subsalicylate. Opioid motility
modulator acting on mu receptors in the gut that
provides effective symptomatic management of non-
infectious diarrhoea, especially in foals. Frequently used in
combination with loperamide. Similarity in mode of action
to loperamide brings synergistic action.

Loperamide Purpose: diarrhoea treatment in foals.

Identification of alternatives: bismuth subsalicylate.
Discussion of the specific advantages: different mode of
action to bismuth subsalicylcate. Opioid motility
modulator acting on mu receptors in the gut that
provides more effective symptomatic management of
non-infectious diarrhoea in foals than other substances.
Frequently used in combination with codeine. Similarity
in mode of action to codeine brings synergistic action.

Metoclopramide Purpose: treatment of post-operative ileus.

Identification of alternatives: bethanechol, erythromycin.
13.2.2013 EN Official Journal of the European Union L 42/11

Indication Active substance Justification and explanation of use

Discussion of the specific advantages: Metoclopramide is a

substituted benzamide with several mechanisms of action:
(1) it is a dopamine receptor antagonist; (2) it augments the
release of acetylcholine from intrinsic cholinergic neurons;
and (3) it has adrenergic blocking activity. It is effective in
restoring gastrointestinal coordination post operatively and
it decreases the total volume, rate and duration of gastric
reflux. Metaclopramide is a prokinetic drug, which acts
more in the proximal gastrointestinal tract. Both
betanechol and metoclopramide have been shown to be
beneficial in the treatment of post-operative ileus.

Phenoxy-benzamine Purpose: diarrhoea treatment; colitis.

Identification of alternatives: bismuth subsalicylate; flunixin.
Discussion of the specific advantages: has different mode of
action (alpha-1 antagonist and antisecretion agent)
compared to other authorised treatments and codeine.
Provides useful symptomatic management of diarrhoea
and colitis.

Propantheline bromide Purpose: anti-peristaltic.

Identification of alternatives: atropine, lidocaine given
diluted intrarectally as an enema.
Discussion of the specific advantages: propantheline
bromide is a synthetic quaternary ammonium anticholi­
nergic which inhibits gastrointestinal motility and spasm
and diminishes gastric acid secretion. It also inhibits the
action of acetylcholine at the postganglionic nerve endings
of the parasympathetic nervous system. Its effects are
similar to those of atropine although they last longer (six
hours). Propantheline bromide is an important choice for
decreasing peristalsis to avoid rectal tearing during rectal
palpation or to explore and treat a potential rectal tear
where it can be difficult to get a lidocaine enema to
work effectively.

Ranitidine Purpose: gastric ulcer prophylaxis in neonates.

Identification of alternatives: omeprazole.
Discussion of the specific advantages: different mode of
action from omeprazole. Route of administration (intra­
venous) brings added benefit over all other anti-ulcer medi­
cations as these require oral administration. Intravenous
ranitidine preparation essential in foals that have absent
gastrointestinal motility, the group that are at high risk
for ulcers.

Sucralfate Purpose: gastric ulcer prophylaxis in neonates.

Identification of alternatives: omeprazole.
Discussion of the specific advantages: different mode of
action from omeprazole and valuable adjunctive gastric
ulcer prophylaxis. Unique mode of action (mucosal
adherent) provides physical lesion stabilisation.

Rhabdomyolysis

Dantrolene sodium Purpose: treatment of rhabdomyolysis. Treatment of

malignant hyperthermia during anaesthesia.
Identification of alternatives: phenytoin.
Discussion of the specific advantages: dantrolene exhibits
muscle relaxation activity by direct action on muscle as it
inhibits the release of calcium from the sarcoplasmic
reticulum and thus causes a dissociation of excitation-
contraction coupling. Both phenytoin and dantrolene
sodium have been found to be useful in the treatment of
recurrent forms of rhabdomyolysis.
L 42/12 EN Official Journal of the European Union 13.2.2013

Indication Active substance Justification and explanation of use

Antimicrobials

Klebsiella spp. infections Ticarcillin Purpose: treatment of Klebsiella spp. infections.

Identification of alternatives: none identified.
Discussion of the specific advantages: specific antibiotic for
Klebsiella spp. infections.

Rhodococcus equi infections Azithromycin Purpose: treatment of Rhodococcus equi infections.

Identification of alternatives: erythromycin.
Discussion of the specific advantages: standard treatment in
combination with rifampicin, better tolerated in foals than
erythromycin.

Rifampicin Purpose: treatment of Rhodococcus equi infections.

Identification of alternatives: none identified.
Discussion of the specific advantages: treatment of Rhodo­
coccus equi in combination with erythromycin or
azithromycin. Treatment of choice.

Septic arthritis Amikacin Purpose: treatment of septic arthritis.

Identification of alternatives: gentamicin or other aminog­
lykosides.
Discussion of the specific advantages: better tolerated in
foals than gentamicin or other aminoglykosides.

Respiratory medicines

Ambroxol Purpose: stimulation of surfactant in the premature foal.

Identification of alternatives: none identified.
Discussion of the specific advantages: no alternatives avail­
able.

Budesonide Purpose: inhalation corticosteroid for control of allergic

pulmonary disease.
Identification of alternatives: beclomethasone.
Discussion of the specific advantages: inhalation corticos­
teroid therapy causes less adreno-cortical suppression, with
more rapid return to normal function after therapy ends,
and fewer systemic side effects than systemic corticosteroid
therapy because of limited systemic absorption. Inhalation
allows reduced doses and local delivery of high concen­
trations of active substance and hence greater efficacy.
Especially useful for control of mild-moderate disease and
long-term maintenance therapy. Additional substances with
greater potency and different durations of effect than
beclomethasone are required to titrate the dose based on
clinical response and provide optimum disease control.
Budesonide has intermediate potency between beclome­
thasone and fluticasone.

Fluticasone Purpose: inhalation corticosteroid for control of allergic

pulmonary disease.
Identification of alternatives: beclomethasone.
Discussion of the specific advantages: inhalation corticos­
teroid therapy causes less adreno-cortical suppression with
quick rebound after therapy ends and fewer systemic side
effects than systemic corticosteroid therapy because of
limited systemic absorption. Inhalation allows local
delivery of high concentrations of active substance and
hence greater efficacy. Especially useful for control of
13.2.2013 EN Official Journal of the European Union L 42/13

Indication Active substance Justification and explanation of use

mild-moderate disease and long-term maintenance therapy.

Additional substances with greater potency and different
durations of effect than beclomethasone are required to
titrate the dose based on clinical response and provide
optimum disease control. Fluticasone is 50 % more
potent than beclomethasone and has longer half life (6
hours versus 2,8 hours), providing added benefit for
more severely affected or refractory cases.

Ipratropium bromide Purpose: bronchodilation.

Identification of alternatives: none identified.
Discussion of the specific advantages: anticholinergic
action. Necessary as therapeutic choice as in some cases
more efficacious than β-agonists.

Oxymetazolin Purpose: treatment of nasal oedema.

Identification of alternatives: phenylephrine.
Discussion of the specific advantages: α-adrenoceptor
agonist with strong vasoconstrictive properties which is
used in preference to phenylephrine due to the fact that
it is longer-acting.

Antiprotozoal agents

Isometamidium Purpose: treatment of equine protozoal myeloencephalitis.

Identification of alternatives: pyrimethamine.
Discussion of the specific advantages: disease sometimes
refractory to treatment with pyrimethamine, and
therefore an alternative is required.

Ponazuril Purpose: equine protozoal myelitis (Sarcocystis neurona)

treatment.
Identification of alternatives: isometamidium, pyrime­
thamine.
Discussion of the specific advantages: different mode of
action compared to other authorised substances, useful as
alternative therapy when disease refractory to other treat­
ments. Reduced incidence of side effects (diarrhoea)
compared to pyrimethamine/sulphonamide treatments;
increased clinical efficacy compared to isometamidium
and pyrimethamine.

Pyrimethamine Purpose: treatment of equine protozoal myeloencephalitis.

Identification of alternatives: isometamidium.
Discussion of the specific advantages: at least 75 % success
rate when used in conjunction with sulfadiazine-sulfona­
mide.

Ophthalmic medicines

Ocular ulcers Acyclovir Purpose: treatment of ocular ulcers (antiviral medicine).

Topical use.
Identification of alternatives: idoxuridine.
Discussion of the specific advantages: both acyclovir and
idoxuridine have been shown to be equally effective in the
treatment of ulcerative herpetic keratitis.

Idoxuridine Purpose: treatment of ocular ulcers (antiviral medicine).

Topical use.
Identification of alternatives: acyclovir.
Discussion of the specific advantages: both acyclovir and
idoxuridine have been shown to be equally effective in the
treatment of ulcerative herpetic keratitis.
L 42/14 EN Official Journal of the European Union 13.2.2013

Indication Active substance Justification and explanation of use

Glaucoma Phenylephrine Purpose: treatment of glaucoma, epiphora, nasal oedema

and splenic entrapment.
Identification of alternatives: tropicamide, (for glaucoma),
otherwise none identified.
Discussion of the specific advantages: both phenylephrine
and tropicamide have been shown to be equally effective in
the treatment of glaucoma.

Tropicamide Purpose: treatment of glaucoma. Topical use.

Identification of alternatives: phenylephrine.
Discussion of the specific advantages: both phenylephrine
and tropicamide have been shown to be equally effective in
the treatment of glaucoma.

Dorzolamide Purpose: treatment of glaucoma. Topical use.

Identification of alternatives: latanoprost, timolol maleate.
Discussion of the specific advantages: its specific mode of
action as a carbonic anhydrase inhibitor. Important thera­
peutic choice.

Latanoprost Purpose: treatment of glaucoma. Topical use.

Identification of alternatives: dorzolamide, timolol maleate.
Discussion of the specific advantages: its specific mode of
action as a prostaglandin F2α-analogue. Important thera­
peutic choice.

Timolol maleate Purpose: treatment of glaucoma. Topical use.

Identification of alternatives: dorzolamide, latanoprost.
Discussion of the specific advantages: its specific mode of
action as a non-selective beta-adrenergic receptor blocking
agent, causes vasoconstriction, which in turns leads to
decrease of the aqueous humour. Important therapeutic
choice.

Cyclosporin A Purpose: immunosuppressive used for the treatment of

autoimmune diseases of the eye.
Identification of alternatives: none identified.
Discussion of the specific advantages: no alternatives avail­
able.

Ketorolac Purpose: treatment of eye pain and inflammation, non-

steroidal anti-inflammatory medicine, eye drops, topical
use.
Identification of alternatives: none identified.
Discussion of the specific advantages: widest clinical
experience with ketorolac compared to other potential
candidates for essential substances.

Ofloxacin Purpose: treatment of eye infections resistant to commonly

used ophthalmic antibiotic treatments.
Identification of alternatives: none identified.
Discussion of the specific advantages: widest clinical
experience with ofloxacin compared to other potential
candidates for essential substances. Compared to
commonly employed ophthalmic antibiotic treatments
ofloxacin should only be used as a reserve antibiotic in
individual cases.

Fluoresceine Purpose: diagnostic tool for corneal ulceration, topical use.

Identification of alternatives: Rose Bengal.
13.2.2013 EN Official Journal of the European Union L 42/15

Indication Active substance Justification and explanation of use

Discussion of the specific advantages: Rose Bengal has

some antiviral activity while fluoresceine has no significant
effect on virus replication. Thus, the diagnostic use of Rose
Bengal prior to viral culture may preclude a positive result.
Therefore fluoresceine is the diagnostic tool of choice when
a viral culture is planned.

Rose Bengal Purpose: diagnostic tool for early corneal damage, topical
use.
Identification of alternatives: fluoresceine.
Discussion of the specific advantages: Rose of Bengal is the
diagnostic tool of choice to ascertain very early corneal
damage.

Hyperlipaemia

Insulin Purpose: treatment of hyperlipaemia, used in combination

with glucose therapy, diagnosis of metabolic disorders.
Identification of alternatives: none identified.
Discussion of the specific advantages: no alternatives avail­
able.

Fungal infections

Griseofulvin Purpose: systemic antifungal use. Treatment of ringworm.

Identification of alternatives: none identified.
Discussion of the specific advantages: griseofulvin given
orally has good activity against trichophyton, micro­
sporum, and epidermophyton.

Ketoconazole Purpose: systemic antifungal use. Treatment of fungal

pneumonia and guttural pouch mycosis.
Identification of alternatives: none identified.
Discussion of the specific advantages: widest clinical
experience with ketoconazole compared to other
potential candidates for essential substances.

Miconazole Purpose: treatment of fungal infections of the eye.

Identification of alternatives: none identified.
Discussion of the specific advantages: topical use on the
affected eye, wider antifungal activity and/or lesser irritation
than other antifungal agents.

Nystatin Purpose: treatment of yeast infections for eyes and genital

tract.
Identification of alternatives: none identified.
Discussion of the specific advantages: specific activity
against yeast infections.

Diagnostic imaging

Radiopharma-ceutical Purpose: scintigraphy.

Tc99m
Identification of alternatives: none identified.
Discussion of the specific advantages: most sensitive diag­
nostic imaging modality for identification of early bone
pathology and fractures — more sensitive than radi­
ography. Allows quantitation and enables imaging of
regions not amenable to radiography. Essential imaging
technique safeguarding welfare of performance horses
through early injury detection and prevention of cata­
strophic fractures. Short half life (6,01 hours) of Tc99m
results in rapid clearance of detectable radioactivity (< 72
hours) from the horse.
L 42/16 EN Official Journal of the European Union 13.2.2013

Indication Active substance Justification and explanation of use

Miscellaneous

Carbamazepine Purpose: headshaking syndrome.

Identification of alternatives: none identified.
Discussion of the specific advantages: carbamazepine is
acting as anti-convulsant with sodium channel-blocking
effects. Used mainly for treatment and diagnostic confir­
mation of trigeminal neuralgia (headshaking syndrome).

Cyproheptadine Purpose: headshaking syndrome.

Identification of alternatives: none identified.
Discussion of the specific advantages: horses exhibiting
signs of photic headshaking respond favourably to
treatment with the antihistaminic drug cyproheptadine. In
addition to antihistaminic action, cyproheptadine has anti­
cholinergic action and is a 5-hydroxytryptamine (serotonin)
antagonist. Relief from the behaviour is usually seen within
24 hours of beginning cyproheptadine therapy and often
resumes within 24 hours of discontinuing therapy. Other
antihistamines are not effective at eliminating headshaking.

Domperidone Purpose: agalactia in mares.

Identification of alternatives: none identified.
Discussion of the specific advantages: dopamine antagonist
and up-regulates prolactin production.
Oxytocin is not a suitable alternative because it produces
milk letdown as opposed to increasing milk production,
which is the aim of domperidone therapy. Additionally,
oxytocin is likely to cause abdominal pain if used in
large doses.

Gabapentin Purpose: neuropathic pain.

Identification of alternatives: buprenorphine, fentanyl,
morphine, pethidine.
Discussion of the specific advantages: different mode and
different site of action to alternative authorized substances.
GABA-like substance which blocks calcium channels and
inhibits formation of new synapses. Novel treatment for
neuropathic pain with evidence suggesting added clinical
benefit in the management of pain related to neuropathy
e.g. foot pain, laminitis and abdominal pain.

Hydroxyethyl-starch Purpose: colloidal volume substitution.

Identification of alternatives: none identified.
Discussion of the specific advantages: practical and readily
available alternative to blood or plasma.

Imipramine Purpose: pharmacologically induced ejaculation in stallions

with ejaculatory dysfunction.
Identification of alternatives: none identified.
Discussion of the specific advantages: no alternatives avail­
able.

Thyrotropin releasing Purpose: diagnostic used for the confirmation of thyroid

hormone and pituitary disorders.
Identification of alternatives: none identified.
Discussion of the specific advantages: no alternatives avail­
able.

Barium sulphate Purpose: radiographic contrast agent used for oesophageal

and gastrointestinal contrast examinations.
Identification of alternatives: none identified.
Discussion of the specific advantages: no alternatives avail­
able.
13.2.2013 EN Official Journal of the European Union L 42/17

Indication Active substance Justification and explanation of use

Iohexol Purpose: radiographic contrast agent used for lower urinary

tract studies, arthrography, myelography, sino- or fistu­
lography and dacryocystography.
Identification of alternatives: iopamidol.
Discussion of the specific advantages: non-ionic low
osmolar contrast agent. Both iohexol and iopamidol are
equally acceptable.

Iopamidol Purpose: radiographic contrast agent used for lower urinary

tract studies, arthrography, myelography, sino- or fistu­
lography and dacryocystography.
Identification of alternatives: iohexol.
Discussion of the specific advantages: non-ionic low
osmolar contrast agent used for. Both iohexol and
iopamidol are equally acceptable.’
 Article #4

CE
Laryngeal Paralysis: Pathophysiology,
Diagnosis, and Surgical Repair
John F. Griffin IV, DVM
D. J. Krahwinkel, DVM, MS, DACVS, DACVA, DACVECC
University of Tennessee

ABSTRACT:
Dysfunction of the recurrent laryngeal nerves causes laryngeal paralysis in dogs and cats.
Paralysis of the cricoarytenoideus dorsalis muscle results in an inability to abduct the ary-
tenoid cartilages during inspiration.The resulting cross-sectional area of the glottis is inade-
quate for normal respiration.The most common clinical signs of laryngeal paralysis in dogs
and cats are stridor, exercise intolerance, respiratory distress, and a change in phonation. A
variety of surgical procedures have been used to successfully treat laryngeal paralysis in
dogs and cats. Arytenoid lateralization appears to give the best clinical outcome.

L
aryngeal paralysis results when the abduc-
tor muscles of the larynx are disrupted.
The larynx does not open during inspira-
tion because the arytenoid cartilages fail to
retract. The disease may be unilateral but more
often occurs bilaterally. Laryngeal paralysis is a
common, important cause of upper respiratory
obstruction in dogs1 and is increasingly being
recognized in cats.2 Although laryngeal paralysis
was once thought to be an isolated clinical
entity, recent reports suggest that the condition
is only one manifestation of a generalized neu-
romuscular disorder.3,4 This article provides a
metaanalytical overview of the current literature
on laryngeal paralysis, describes recent advances
in diagnostic techniques, and reviews surgical
procedures used for correction. A review of
laryngeal paralysis in cats is also provided.
EPIDEMIOLOGY
Send comments/questions via email Laryngeal paralysis is most
editor@CompendiumVet.com often diagnosed in geriatric
or fax 800-556-3288.
large- and giant-breed dogs
Visit CompendiumVet.com for but can also occur in a num-
full-text articles, CE testing, and CE ber of small breeds. 5,6 Most
test answers. studies 3,7–12 report that male
dogs are more commonly affected than female
dogs. Reported canine male:female ratios range
from 3.7:1 to 1:1.11,12 The mean age range of
dogs treated surgically for laryngeal paralysis is
9.5 to 12.2 years of age.3,7–12 Labrador retrievers
are most commonly affected with acquired
laryngeal paralysis.1 Other commonly affected
large and giant breeds include the St. Bernard,
Irish setter, and Afghan hound.3,7–12
One report 1 described the prevalence of
laryngeal paresis and paralysis in a population
of dogs undergoing general anesthesia at a
university veterinary teaching hospital. The
investigators performed laryngoscopy on 250
dogs, assigning each dog a subjective score of 0
(i.e., normal) to 4 (i.e., completely paralyzed).
One-quarter of the dogs examined had some
degree of laryngeal paresis. Laryngeal scores
were significantly and directly related to age,
body weight, and body condition score.
Labrador retrievers and rottweilers were at
least twice as likely to be affected as other
breeds. No effort was made to standardize the
anesthetic protocol. This could be important
because the most commonly used anesthetic
drugs depress laryngeal motion.13

November 2005 857 COMPENDIUM

858 CE Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair
Stridor
Exercise intolerance
Clinical signs
Respiratory distress
Change in phonation
Cyanosis
Cough or gag
Fever
Collapse
0 20 40 60 80
Percentage of cases
Figure 1. Graph depicting the most common clinical
signs of laryngeal paralysis in dogs. These figures represent
data from several retrospective studies.6–12
LARYNGEAL PARALYSIS IN
IMMATURE DOGS
Laryngeal paralysis occurs in immature Bouvier des
Flandres, Siberian huskies, dalmatians, rottweilers,
Leonbergers, and bullterriers.6,14–18 Laryngeal paralysis
has also been reported in a young Afghan hound, a
cocker spaniel, a dachshund, and a miniature pinscher.6,14
Hereditary laryngeal paralysis was first described in
the Bouvier des Flandres and is transmitted as an auto-
somal dominant trait in this breed.14,19,20 This can be
seen as a single clinical entity or as part of a polyneu-
ropathy. 3 Microscopic, degenerative lesions of the
nucleus ambiguous of the brain stem have been
described.19 However, these changes alone fail to explain
the distal distribution of neurogenic atrophy and com-
mon peroneal nerve changes in an 8-month-old male
Bouvier des Flandres in another report.3
Less is known about hereditary laryngeal paralysis in
other canine breeds. Laryngeal paralysis in young Siber-
ian huskies and husky crossbreeds is thought to occur
most often as a single clinical entity in dogs with blue
eyes and white faces with “freckles.” 21 Preliminary
breeding studies have been unable to describe the mode
of heritability.
Five rottweilers (three of which were related) with
laryngeal paralysis–polyneuropathy complex had an on-
set of clinical signs at 9 to 13 weeks of age.17 Four had
bilateral cataracts, one had megaesophagus, and all five
had inspiratory stridor. Mild to moderate muscular
weakness was noted, with the hindlimbs more severely
COMPENDIUM
affected than the forelimbs. No sex predilection was
identified.
Fourteen dalmatians with lar yngeal paralysis–
polyneuropathy complex had an onset of clinical signs at
2 to 12 months of age.16 Nine dogs had polyneuropathy,
manifested as weakness, hypotonia, and hyporeflexia,
principally distal to the elbow and stifle. Nine dogs had
megaesophagus. The mean observation period between
onset of clinical signs and euthanasia or death was 3.7
months. No sex predilection was identified.
Laryngeal paralysis was seen in Leonbergers 1 year of
age and older.22 Clinical signs included exercise intoler-
ance, weakness, gait abnormalities, change in phonation,
and dyspnea. Affected dogs had distal limb muscle atro-
phy, decreased spinal and cranial nerve reflexes, and
decreased to absent movement of the laryngeal and pha-
ryngeal muscles. Electromyogram studies suggested
denervation of distal muscles. Nerve conduction veloci-
ties were decreased. Peripheral nerve biopsies showed a
loss of axons and a shift toward smaller diameter myeli-
nated fibers. Laryngeal paralysis appears to follow an X-
linked pattern of inheritance in Leonbergers.
CLINICAL SIGNS
Clinical signs of laryngeal paralysis in dogs include stri-
dor, exercise intolerance, respiratory distress, change in
phonation, cyanosis, cough or gag, fever, and collapsed
(Figure 1). 6–12 Hyperthermia and heatstroke may be
observed, resulting from inability to adequately ventilate
through panting. Clinical signs occur inconsistently until
laryngeal paresis develops into paralysis.1 Some animals
also show other signs related to neuromuscular dysfunc-
tion, such as limb weakness or dysphagia.
CAUSE AND PATHOPHYSIOLOGY
The cause of laryngeal paralysis can be genetic, as
mentioned previously, or acquired. The cause of the
acquired form is most commonly described as idio-
pathic.7 Other causes of laryngeal paralysis include neo-
plasia, trauma, infection, or a surgical complication in
the cervical or thoracic region.5,7,23 Myasthenia gravis
has been implicated as a cause of laryngeal paralysis.24
The mechanism of idiopathic laryngeal paralysis in
dogs is described as a progressive, noninflammatory,
degenerative disease of the recurrent laryngeal nerves.25
Histopathologic characteristics of the recurrent laryn-
geal nerves include loss of axons, beading of myelin, and
perineural fibrosis. Neurogenic atrophy of the cricoary-
tenoideus dorsalis muscle has been noted.
November 2005
 Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair CE
Bilateral laryngeal paralysis occurs in 81% to 100% of
dogs with laryngeal paralysis presenting for surgery.7,12
Dogs may have symmetric or asymmetric laryngeal
paralysis.10 Everted laryngeal saccules, elongated soft
palate, laryngeal edema, and moderate to severe laryn-
geal collapse may play a role in upper airway obstruction
secondary to laryngeal paralysis.6 Patients with laryngeal
paralysis commonly have diffusely inflamed laryngeal
mucosa. The reason for this is unknown.
LARYNGEAL PARALYSIS AS ONE
MANIFESTATION OF POLYNEUROPATHY
Changes in distal tibial and common peroneal nerve
biopsy samples in young and old dogs with laryngeal
paralysis and polyneuropathy have been described.3 The
predominant changes in teased nerve fiber studies were
fiber degeneration or demyelination and remyelination.
Electrophysiologic changes indicative of a dying back
neuropathy (i.e., axonal degeneration specifically target-
ing the distal part of long and large diameter nerve
fibers) were noted in all dogs. The study authors suggest
that laryngeal paralysis is only one clinical sign of an
underlying, more generalized polyneuropathy with vari-
able clinical expression of neurologic signs.
Laryngeal paralysis is usually only one manifestation
of generalized neuromuscular disease.
In one report,12 56% of dogs treated surgically for
laryngeal paralysis had posterior weakness before or
after surgery. Instances of confirmed neurologic disease
range from 2% to 22% of dogs treated surgically for
laryngeal paralysis.5,10,11 Many reports5–7,9,11,12 of surgical
treatment of laryngeal paralysis did not include a com-
plete neurologic examination as part of the minimum
database.
CONCURRENT DISEASE
The relationship between hypothyroidism and laryn-
geal paralysis is unclear; however, many dogs with laryn-
geal paralysis are concurrently hypothyroid. 3,11,26
Hypothyroidism could represent a causative or predis-
posing factor or could merely be coincidental.5–7,9,11,12
Resolution of laryngeal paralysis in supplemented
hypothyroid dogs has been poorly described.27 In con-
trast, hypothyroid polyneuropathy (with no concurrent
November 2005
859
laryngeal paralysis) usually responds to thyroid supple-
mentation. A possible explanation for this disparity
could be that laryngeal paralysis is usually diagnosed as
an end-stage disease after irreversible atrophy of the
cricoarytenoideus dorsalis muscle has already occurred.1
Dogs receiving adequate thyroid supplementation have
reportedly developed laryngeal paralysis.5
Dogs with laryngeal paralysis are reportedly 21 times
more likely to have megaesophagus compared with con-
trol groups. 24 Laryngeal paralysis was diagnosed in
11.8% of dogs with acquired megaesophagus. Concur-
rent megaesophagus is a negative prognostic indicator.
It has been speculated that laryngeal paralysis associ-
ated dysphagia or megaesophagus predisposes patients
to aspiration pneumonia.28 Reported instances of pneu-
monia at the time of presurgical evaluation ranged from
7% to 10%.9,10 Nearly one-quarter of dogs treated surgi-
cally for laryngeal paralysis developed aspiration pneu-
monia at some point.5
DIAGNOSIS
Clinical suspicion is an important tool in diagnosing
laryngeal paralysis.1 Clinical suspicion was reportedly
91.6% sensitive and 98.5% specific for severe laryngeal
paralysis in 250 dogs anesthetized at a veterinary teach-
ing hospital. This comparison used laryngoscopic obser-
vation as the definitive diagnostic procedure.
The accepted standard of diagnosis is direct visualiza-
tion of the arytenoid cartilages by laryngoscopy with the
patient under light anesthesia6,7,9,11,12 (Figure 2). The pres-
ence of abnormal laryngeal function in clinical cases has
been based on the subjective opinion of the surgeon.
There is a reported 95% agreement between two
observers in assigning 17 dogs a laryngeal paralysis score.1
A potential problem with diagnosing laryngeal paralysis
is that anesthetic agents normally depress laryngeal
movement. In normal dogs, anesthetic depths necessary
to alleviate jaw tone to safely and easily visualize the lar-
ynx may prevent laryngeal motion.13,29 The paralysis may
be bilateral (Figure 3) or unilateral (Figure 4).
A comparison of various anesthetic protocols for
laryngeal function in normal dogs has been reported.13
COMPENDIUM
 860 CE Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair
Arytenoid
Vocal folds
Figure 2. Drawing of the normal larynx as seen via
laryngoscopy. The arytenoid cartilages are adducted, and the
vocal folds are obvious in the glottic opening. (Haines DK © 2005
The University of Tennessee College of Veterinary Medicine)
Two anesthetic protocols, intravenous thiopental alone
and intramuscular acepromazine with intramuscular
butorphanol plus isoflurane by mask, had the least
effect on laryngeal motion. Intravenous propofol, intra-
venous ketamine plus intravenous diazepam, intramus-
cular acepromazine plus intravenous thiopental, or
intramuscular acepromazine plus intravenous propofol
caused
aines ©2005 more depression
The university of laryngeal
of Tennessee College motion.
of Veterinary This study
Medicine
suggests that use of the latter anesthetic protocols could
cause misdiagnosis of laryngeal paralysis. Another
report29 suggests that intravenous thiopental and intra-
venous propofol are superior to intravenous ketamine
plus intravenous diazepam because they more effec-
tively alleviate jaw tone.
Another study30 evaluated use of doxapram HCl (1.1
mg/kg IV ) as a respiratory stimulant in dogs anes-
thetized with acepromazine, butorphanol, and isoflu-
rane. Depth of respiration increased in normal dogs, but
ar ytenoid motion did not change in response to
doxapram HCl injection. Dogs affected by laryngeal
paralysis developed paradoxical arytenoid motion and a
decrease in glottal area. The authors concluded that
doxapram HCl administration may be useful in differ-
entiating between normal and affected dogs. Affected
dogs may experience extreme glottic constriction and
require intubation during examination.
Transnasal laryngoscopy in dogs has been recently
COMPENDIUM
Figure 3. Laryngoscopic view of a patient with bilateral
laryngeal paralysis. The arytenoid cartilages are immobile and
moderately inflamed, which is typical in patients with laryngeal
paralysis.
described.31 This technique is an adaptation of the well-
accepted means of diagnosing laryngeal paralysis in
horses. The authors were able to successfully assess nor-
mal and abnormal laryngeal function in dogs sedated
with an opioid and acepromazine. This technique elim-
inated the need for general anesthesia to diagnose
laryngeal paralysis. A 2.5-mm flexible endoscope was
passed through the nasal passages of dogs treated with
intranasal lidocaine. The technique successfully differ-
entiated between three normal dogs and four dogs
affected with laryngeal paralysis. All of the dogs resis-
ted lidocaine application and initial placement of the
endoscope. If no laryngeal motion was observed, the
authors mechanically stimulated the laryngeal mucosa
to differentiate normal from abnormal dogs. Normal
dogs began moving the arytenoids, whereas affected
dogs did not. Limitations of the technique include the
need for a small, flexible endoscope and a large patient.
Use of ultrasonography has been described for diag-
nosing laryngeal paralysis in dogs.32 With direct transo-
ral lar yngoscopy used as a definitive diagnostic
procedure, motion of the cuneiform processes of the
arytenoid cartilages was correctly observed in 10 of 10
normal dogs and 29 of 30 dogs with unilateral or bilat-
November 2005
 Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair CE 861

eral laryngeal paralysis. The one instance of disagree-

ment was when ultrasonography suggested unilateral
involvement but laryngoscopy showed bilateral involve-
ment. Advantages of this technique are that it is rapid
and noninvasive and does not require sedation or anes-
thesia. Disadvantages are that it requires technical
expertise and expensive equipment. Difficulties are
encountered with large, obese dogs and very calm dogs
with shallow breathing.
Computer programs using the normalized glottal gap
area have been used to quantitatively measure the glottal
opening and thereby laryngeal function.13,33 This has
enabled investigators to compare anesthetic agents used
for diagnosis and the efficacy of surgical techniques in
relieving upper airway obstruction.
Historically, tidal breathing flow–volume loops
(TBFVL) and arterial blood gas analysis have been used Figure 4. Laryngoscopic view of a patient with
to characterize the type and severity of upper airway unilateral laryngeal paralysis. Note the abduction of the left
obstruction and response to surgical correction. 34,35 arytenoid cartilage.
TBFVL has not been used clinically in any of the major
surgical technique reviews.5–12 The logistical challenges of
TBFVL likely preclude its clinical use because it requires gram should be considered. Conversely, dogs diagnosed
a voluntary maximal tidal volume, which is difficult to with megaesophagus and/or aspiration pneumonia
achieve in animals. Blood gas analysis is probably not should be screened closely for laryngeal paralysis. 24
routinely conducted because it was shown that blood gas Serum acetylcholine receptor antibody tests could be
abnormalities are directly related to severity of clinical considered to rule out myasthenia gravis, especially in
signs and are not specific for a particular disease.35 dogs with megaesophagus. 24 Thyroid function tests
Electromyography of the cricoarytenoideus dorsalis should be conducted to rule out hypothyroidism.27

Although laryngeal paralysis most often

affects geriatric large-breed dogs, it can affect
young dogs of a number of breeds.
muscle has been successfully used to confirm laryngeal
paralysis.6 However, this technology requires specialized
equipment and a highly trained electrophysiologist.
EVALUATING FOR CONCURRENT
DISEASE
The possibility of concurrent disease makes additional
diagnostic testing necessary in patients suspected of
having laryngeal paralysis. Thoracic radiographs should
be taken to rule out aspiration pneumonia, intrathoracic
mass, and megaesophagus.5,9,10,24 Cervical radiographs
have been recommended to rule out neoplasia.11 If dys-
phagia or regurgitation is reported, a barium esopha-
A complete neurologic examination should be per-
formed on all dogs and cats with laryngeal paralysis.
Patients with neurologic abnormalities in addition to
laryngeal paralysis should be considered as candidates
for electrophysiology and muscle and nerve biopsies.
Alternatively, animals presenting with polyneuropathy
should be carefully evaluated for laryngeal paralysis.3
MEDICAL TREATMENT
Medical treatment of laryngeal paralysis involves
symptomatic treatment of hypoxia, hyperthermia,
excitement, and obesity. Oxygen therapy, cooling, exer-
cise restriction, stress avoidance, and caloric restriction

November 2005 COMPENDIUM

 862 CE Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair
Arytenoid
Vocal folds removed
Figure 5. Drawing of an endoscopic view of ventriculo-
cordectomy. The vocal cords have been removed bilaterally, leaving
the most ventral ends uncut to prevent “webbing.” (Haines DK
© 2005 The University of Tennessee College of Veterinary Medicine)
are advised.36,37 Identification and treatment of concur-
rent disease may be beneficial. Some benefit may be
dkhaines ©2005 The university of Tennessee College of Veterinary Medicine
gained by thyroid supplementation in hypothyroid
dogs.27 Corticosteroids have been advocated to decrease
laryngeal inflammation.36,37 There is no proven effica-
cious drug therapy for similar polyneuropathies in
humans.38
SURGICAL TREATMENT
A variety of surgical procedures are used to treat laryn-
geal paralysis. Some are aimed at enlarging the laryngeal
opening by removing one or both of the vocal folds (i.e.,
ventriculocordectomy) and arytenoid cartilages (i.e.,
partial laryngectomy). Some procedures seek to lateral-
ize one or both arytenoid cartilages (tieback), whereas
others seek to widen the larynx by widening the thyroid
cartilage (i.e., laryngofissure). A description and brief
review of each of these techniques follow.
Ventriculocordectomy
Ventriculocordectomy has been described for treating
laryngeal paralysis.9 The dog is anesthetized with an
injectable agent and positioned in sternal recumbency
with the head elevated. Alternately, a tracheostomy may
be performed and the patient maintained under inhalant
anesthesia. The mouth is opened with the aid of a den-
COMPENDIUM
Arytenoid
Vocal fold
Figure 6. Drawing of an endoscopic view of partial
arytenoidectomy. A portion of the corniculate process of the
arytenoid cartilage and vocal folds has been removed. (Haines DK
© 2005 The University of Tennessee College of Veterinary Medicine)
dkhaines ©2005 The university of Tennessee College of Veterinary Medicine
tal speculum and the tongue retracted cranially. An
assistant elevates the soft palate and depresses the
epiglottis with the blade of a laryngoscope, permitting
visualization of the larynx. Long forceps and scissors or
biopsy forceps are used to reach inside the laryngeal
opening and remove the vocal folds from the larynx
(Figure 5). To prevent laryngeal “webbing,” the most
ventral one-quarter of the vocal fold should not be
excised. Simple removal of the vocal folds in some
patients provides enough of an airway that the animal
does not need additional surgery.9 This is especially true
for inactive animals. The complication of “webbing”
may be minimized by using a ventral laryngotomy
approach to the vocal folds. The folds are removed
under direct visualization and the mucosa reapposed
over the excised edges using a 4-0 monofilament
absorbable suture.
Partial Arytenoidectomy
Partial arytenoidectomy is often performed in com-
bination with unilateral vocal cord excision as
described above.8 One or both of the vocal folds are
removed. Biopsy forceps are then used to remove the
medial portions of the corniculate processes of the ary-
tenoid cartilages (Figure 6). Surgeons should attempt
to remove 2 to 3 mm of the medial border of this car-
November 2005
 Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair CE
Figure 7. Laryngoscopic view of a cat with bilateral laryngeal paralysis before and after partial arytenoidectomy.
Before arytenoidectomy.
tilage. It is best to remove only cartilage on one side of
the larynx to prevent “webbing” at the dorsal laryngeal
opening. It may be necessary to use a rongeur to
remove portions of the cartilage. A sufficient amount
of laryngeal tissue is removed from one side to provide
an adequate laryngeal opening (Figure 7). Hemorrhage
is controlled by intermittently packing the larynx with
gauze or saline or epinephrine sponges.
Following the partial laryngeal excision, the larynx is
packed with gauze for approximately 10 minutes to pro-
vide hemostasis. After hemorrhage has been controlled,
the upper trachea is aspirated and lavaged, if necessary,
to remove residual blood clots. The animal is main-
tained under anesthesia for another 10 minutes to
ensure that additional hemorrhage does not occur. If a
tracheostomy is used for these procedures, the tube is
left in place for 24 to 48 hours to provide airway man-
agement until laryngeal swelling has subsided.
Laryngeal Tieback
The objective of laryngeal tieback is to enlarge the
laryngeal opening by surgically retracting the arytenoid
November 2005
863
After arytenoidectomy.
cartilage on one side of the larynx.7,12 This is accom-
plished by dissecting the arytenoid cartilage from its
attachments and retracting it caudolaterally to the dorso-
caudal wing of the thyroid cartilage or the dorsocaudal
aspect of the cricoid cartilage. The procedure may be
done on the left or right side. The animal is anesthetized,
and the surgical site over the lateral aspect of the larynx is
prepared for aseptic surgery. The neck is extended over a
small sandbag to elevate the larynx for increased surgical
exposure. A skin incision is made from the level of the
ramus of the mandible, ventral to the jugular vein, to a
level just caudal to the bifurcation of the jugular vein. The
subcutaneous musculature and connective tissues are sep-
arated and the jugular vein and its bifurcation retracted
dorsally by Gelpi retractors. The thyropharyngeus muscle
is incised at its attachment to the rim of the thyroid carti-
lage. The wing of the thyroid cartilage is reflected later-
ally by blunt dissection of the connective tissue on its
medial border and separation of the cricothyroid articula-
tion. The muscular process of the arytenoid cartilage can
usually be palpated as a small protrusion on the lateral
surface of the larynx. The cricoarytenoid muscle that
COMPENDIUM
 864 CE Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair

Figure 9. Laryngoscopic view of a patient with bilateral

laryngeal paralysis before and after thyroarytenoid
Arytenoid
Cricoid lateralization. Note the mild abduction of the arytenoid
cartilage.

Thyroid

Figure 8. Drawing demonstrating a thyroarytenoid

tieback with placement of two sutures from the
muscular process of the arytenoid cartilage to the
dorsocaudal border of the thyroid cartilage. (Haines DK
© 2005 The University of Tennessee College of Veterinary Medicine)

Before thyroarytenoid lateralization.

attaches
dkhaines at this
©2005 point isof usually
The university Tennesseeatrophied, makingMedicine
College of Veterinary the
process particularly prominent.
Dissection begins under the muscular process with
small blunt scissors, mosquito forceps, or a periosteal
elevator, and the arytenoid cartilage is disarticulated
from the cricoid cartilage immediately beneath the mus-
cular process. When dissecting and placing sutures
through the muscular process, surgeons should be
extremely careful not to break the process, which is
fairly easy to do in an elderly animal. This articulation is
identified by the presence of articular cartilage. Once
totally separated from the cricoid cartilage, the muscular
process of the arytenoid cartilage is freely movable. To
gain total mobility, it may be necessary to sever the
sesamoidian band that connects the left and right ary-
tenoid cartilages across the dorsal aspect of the larynx.
This small band of tissue is approximately 1 mm in
diameter and, when excised, allows the arytenoid to
become totally mobilized. After thyroarytenoid lateralization.
Two sutures of 0 (for large dogs) or 3-0 (for small
dogs and cats) monofilament nonabsorbable suture with
a sturdy half-circle taper point needle are placed
through the muscular process of the arytenoid and An alternative and more physiologic suturing tech-
through the dorsocaudal extremity of the wing of the nique involves placing the tieback suture from the mus-
thyroid cartilage8 (Figure 8). When these sutures are cular process of the arytenoid to the dorsocaudal border
tied tightly, the arytenoid is pulled laterally, opening the of the cricoid cartilage.13 Sutures from the arytenoid to
larynx (Figure 9). the cricoid in this procedure approximate the same

COMPENDIUM November 2005

 Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair CE 865

Figure 11. Laryngoscopic view of a patient with bilateral

laryngeal paralysis before and after cricoarytenoid
Arytenoid lateralization. Note that the arytenoid is more lateralized than
with the thyroarytenoid tieback in Figure 9.
Cricoid

Thyroid

Figure 10. Drawing illustrating a cricoarytenoid tieback

with placement of two sutures from the muscular
process of the arytenoid cartilage to the dorsocaudal
aspect of the cricoid cartilage. (Haines DK © 2005 The University
of Tennessee College of Veterinary Medicine)

Before cricoarytenoid lateralization.

dkhaines ©2005 The university of Tennessee College of Veterinary Medicine
function and location as the cricoarytenoideus dorsalis
muscle. This suture is more demanding to place because
exposure of the dorsocaudal cricoid can be difficult. In
placing these sutures, surgeons must be very careful to
retract the esophagus dorsally to avoid injury when
operating on the left side. Preferably, two simple sutures
should be placed from the muscular process of the ary-
tenoid to the caudal rim of the cricoid immediately lat-
eral to the dorsal midline (Figure 10). For right-handed
surgeons, the suture is passed from the cricoid cartilage
cranial to the muscular process. For left-handed sur-
geons, the suture is passed from the muscular process
caudally to the cricoid cartilage. After these sutures have
been placed and one has been tied, the anesthetist
should examine the larynx with a laryngoscope to ensure
that the tieback procedure has resulted in proper lateral-
ization of the arytenoid cartilage (Figure 11). It is very
easy to overabduct the arytenoid cartilage with this pro-
cedure, resulting in dysfunction of the larynx after sur-
After cricoarytenoid lateralization.
gery due to inability of the epiglottis to totally close the
abducted larynx. It is necessary to move the muscular
process only a few millimeters caudally (Figure 11). The
second suture is tied after the first has been confirmed Modified Castellated Laryngofissure
to be properly placed. Absorbable sutures are used to A seldom-used technique is the modified castellated
reapproximate the severed thyropharyngeus muscle and laryngofissure. The patient is anesthetized and placed
the subcutaneous tissue. The skin is closed with in dorsal recumbency, with the neck arched ventrally,
monofilament nonabsorbable sutures. and the skin over the larynx is prepared for surgery.39,40

November 2005 COMPENDIUM

866 CE Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair
Figure 12. Drawings of the castellated laryngofissure procedure. A, B, and C represent the three segments created by a step
incision of the thyroid cartilage. (Haines DK © 2005 The University of Tennessee College of Veterinary Medicine)
Basihyoid bone
Step
incision
Thyroid
Cricothyroid
ligament
Cricoid
A step incision is made in the thyroid cartilage.
A skin incision is made over the larynx to the fourth
tracheal ring. The sternohyoideus muscle is divided to
expose the thyroid and cricoid cartilages. A tra-
cheotomy tube is inserted into a vertical incision
dkhainesthe
between ©2005 The university
second and third of Tennessee
trachealCollege
rings.of Veterinary
A “step”MedicineNeuromuscular pedicle grafts require 36 to 44 weeks to
incision is made in the thyroid cartilage, and the larynx
is opened (Figure 12). The vocal folds are removed
under direct visualization. The arytenoids are bilaterally
lateralized by monofilament mattress sutures placed
through the thyroid cartilage and the arytenoid carti-
lage dorsal to the vocal process, with the knot outside
the laryngeal lumen. Two or three 3-0 monofilament
nonabsorbable sutures are preplaced between the step
and the cranial segment of the opposite cartilage inci-
sion. The castellated cartilage incision is closed by
aligning the step against the cranial segment of the
opposite cartilage incision, thereby spreading the larynx
by the height of the step. The step is fixed in position
by tightening the preplaced sutures. Sutures from the
thyroid around the basihyoid bone help secure the clo-
sure. Loose tissue and corner edges of cartilage are
trimmed away to prevent them from entering the
lumen of the larynx. The sternohyoideus and sternothy-
roideus muscles are tightly approximated to close the
laryngeal defect. The subcutaneous tissue and skin are
closed routinely. The tracheostomy tube is removed in 3
to 4 days.
COMPENDIUM
Basihyoid bone
Thyroid
Cricothyroid
ligament
Cricoid
The step is distracted and sutured to widen the laryngeal opening.
Other Surgical Options
dkhaines ©2005 pedicle
Neuromuscular The university of Tennessee
grafting College
has been of Veterinary Medicine
investigated
41
in dogs. It is not commonly performed because it does
not provide immediate relief of upper airway obstruction.
return laryngeal movement to normal. Permanent tra-
cheostomy has been recommended as a final alternative
in treating laryngeal paralysis.42 Permanent tracheostomy
can be problematic in dogs that like to swim.
COMPARISON OF DIFFERENT
SURGICAL TECHNIQUES
A 2001 report5 provides the most comprehensive com-
parison of different surgical techniques. The findings
show that both unilateral arytenoid lateralization and
partial laryngectomy offer superior clinical outcome over
bilateral arytenoid lateralization. Complication rates
between unilateral arytenoid lateralization (30%) and
partial laryngectomy (40%) were not significantly differ-
ent. However, dogs treated with partial laryngectomy
were significantly more likely to die of complications
than were dogs treated with unilateral arytenoid lateral-
ization. These complications included aspiration pneu-
monia, respiratory distress, failure of surgical repair, and
death. The complication rate may be higher than in
some other studies because of a longer duration of fol-
low-up. There was not a significant difference in implant
November 2005
 Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair CE
failure between dogs treated with thyroarytenoid lateral-
ization and those treated with cricoarytenoid lateraliza-
tion. Postoperative death rates were highest in dogs
treated with bilateral arytenoid lateralization (67%) com-
pared with unilateral arytenoid lateralization (14%) and
partial laryngectomy (30%). Factors predisposing
patients to death or complications were age, temporary
tracheostomy placement, concurrent respiratory tract
abnormalities, concurrent esophageal disease, postopera-
tive megaesophagus, concurrent neoplastic disease, and
concurrent neurologic disease. A common complication
of the tieback procedure is persistent postoperative
cough, especially after eating or drinking. This is because
the arytenoid cannot adduct and the epiglottis does not
completely close with swallowing.
The most commonly recommended treatment of laryn-
geal paralysis in dogs is unilateral arytenoid lateralization.5
This procedure appears to offer good resolution of clinical
Thorough evaluation for concurrent disease is important
in establishing a therapeutic plan and prognosis for
patients with laryngeal paralysis.
signs with fewer complications than partial laryngec-
tomy.6,10 Unilateral arytenoid lateralization is technically
easier and quicker than castellated laryngofissure.43
One report44 compared the two methods of unilateral
arytenoid lateralization (i.e., thyroarytenoid versus
cricoar ytenoid lateralization). It was shown that
cricoarytenoid lateralization increased the size of the
glottic opening compared with thyroarytenoid lateral-
ization. Cricoarytenoid lateralization did not, however,
result in improved clinical outcome but did require sig-
nificantly less operative time (i.e., 25 minutes compared
with 43 minutes).44
LARYNGEAL PARALYSIS IN CATS
Laryngeal paralysis is becoming more commonly rec-
ognized in cats.2,4 No sex or breed predilection has been
identified. The median age of cats diagnosed with
laryngeal paralysis is 11 years (range: 4 months to 17
years of age).
Half of the affected cats in one report2 were domestic
shorthair. Other breeds represented included domestic
longhair, Siamese, Abyssinian, and Balinese. The same
study reported that clinical signs began at younger than
November 2005
867
3 years of age in 31% of affected cats. Another study4
reported that clinical signs began in two of four cats
younger than 1 year of age.
Clinical signs of laryngeal paralysis in cats include
tachypnea or dyspnea, stridor, exercise intolerance,
change in phonation, dysphagia, weight loss, cough,
anorexia, lethargy, cyanosis, and fever.2,4,45 As in dogs,
laryngeal paralysis in cats may occur in conjunction with
polyneuropathy.4 In one report,4 two of four affected
cats had generalized neuromuscular disease.
Little is known about the pathophysiology of laryngeal
paralysis in cats. Based on the age of cats treated surgically
for laryngeal paralysis, apparently, there are congenital and
acquired causes. How often cats are affected with idio-
pathic laryngeal paralysis is unknown. In one report,2 75%
of affected cats had bilateral laryngeal paralysis. Other
causes of laryngeal paralysis include neoplasia, trauma, or a
surgical complication in the cervical or thoracic region.46,47
As in dogs, affected cats often have concurrent illness.2
Up to 25% have aspiration pneumonia. In one report,4
two of four cats were affected with generalized neuro-
muscular disease. Megaesophagus, FIV infection, and
FeLV infection have been reported in affected cats.2,48
Diagnosis is made by direct visualization of the larynx
in a lightly anesthetized cat.4 Veterinarians have success-
fully treated feline laryngeal paralysis with bilateral ary-
tenoid lateralization,49 unilateral arytenoid lateralization,50
partial laryngectomy,4 and castellated laryngofissure.51
These methods in cats have not been meaningfully com-
pared. Extrapolation of data from dogs suggests that uni-
lateral arytenoid lateralization is the most effective, safe,
and clinically practical surgical technique.37 Tieback pro-
cedures are more difficult in cats than in dogs because of
the small size of the larynx. Dissection is more challeng-
ing, and suture placement must be precise.
CONCLUSION
Laryngeal paralysis is a common, important cause of
upper respiratory obstruction in dogs and is increasingly
being recognized in cats. Recent advances in diagnostic
techniques should help veterinarians correctly identify
COMPENDIUM
868 CE Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair
the problem. Thorough evaluation for concurrent dis-
ease is crucial in providing excellent patient care. Several
surgical alternatives seem to be acceptable, if not ideal,
in treating the problem. Arytenoid tieback surgery
appears to give the best overall results.
REFERENCES
1. Broome C, Burbidge HM, Pheiffer DU: Prevalence of laryngeal paresis in
dogs undergoing general anesthesia. Aust Vet J 78(11):769–772, 2000.
2. Schachter S, Norris CR: Laryngeal paralysis in cats: 16 cases (1990–1999).
JAVMA 216(7):1100–1103, 2000.
3. Braund KG, Steinberg HS, Shores A, et al: Laryngeal paralysis in immature
and mature dogs as one sign of a more diffuse polyneuropathy. JAVMA
194(12):1735–1740, 1989.
4. White RAS, Littlewood JD, Herrtage ME, Clarke DD: Outcome of surgery
for laryngeal paralysis in four cats. Vet Rec 118(4):103–104, 1986.
5. MacPhail CM, Monnet E: Outcome of and postoperative complications in
dogs undergoing surgical treatment of laryngeal paralysis: 140 cases
(1985–1998). JAVMA 218(12):1949–1955, 2001.
6. Harvey CE, O’Brien JA: Treatment of laryngeal paralysis in dogs by partial
laryngectomy. JAAHA 18:551–556, 1982.
7. White RAS: Unilateral arytenoid lateralisation: An assessment of technique
and long-term results in 62 dogs with laryngeal paralysis. J Small Anim Pract
30:543–549, 1989.
8. Trout NJ, Harpster NK, Berg J, Carpenter J: Long-term results of unilateral
ventriculocordectomy and partial arytenoidectomy for the treatment of laryn-
geal paralysis in 60 dogs. JAAHA 30:401–407, 1994.
9. Holt D, Harvey CE: Idiopathic laryngeal paralysis: Results of treatment by
bilateral vocal fold resection in 40 dogs. JAAHA 30:389–395, 1994.
10. Ross JT, Matthiesen DT, Noone KE, Scavelli TA: Complications and long-
term results after partial laryngectomy for the treatment of idiopathic laryn-
geal paralysis in 45 dogs. Vet Surg 20:169–173, 1991.
11. Gaber CE, Amis TC, LeCouteur RA: Laryngeal paralysis in dogs: A review
of 23 cases. JAVMA 186:377–380, 1985.
12. Lahue TR: Treatment of laryngeal paralysis in dogs by unilateral cricoary-
tenoid laryngoplasty. JAAHA 25:317–324, 1989.
13. Jackson AM, Tobias K, Long C, et al: Effects of various anesthetic agents on
laryngeal motion during laryngoscopy in normal dogs. Vet Surg 33:102–106,
2004.
14. Venker-van Haagen AJ, Hartman W, Goedegebuure SA: Spontaneous laryn-
geal paralysis in young Bouviers. JAAHA 14:714–720, 1978.
15. O’Brien JA, Hendriks JC: Inherited laryngeal paralysis in Siberian husky
crosses. Proc Am Coll Vet Intern Med:142, 1985.
16. Braund KG, Shores A, Cochrane S, et al: Laryngeal paralysis–polyneuropa-
thy complex in young dalmatians. Am J Vet Res 55:534–542, 1994.
17. Mahony OM, Knowles KE, Braund KG, et al: Laryngeal paralysis–polyneu-
ropathy complex in young rottweilers. J Vet Intern Med 12:330–337, 1998.
18. Braund KG: Clinical Syndromes in Veterinary Neurology. St Louis, Mosby,
1994, pp 168–170.
19. Venker-van Haagen AJ: Investigations of the pathogenesis of hereditary
laryngeal paralysis in the Bouvier [PhD Thesis]. Utrecht, Netherlands, Proef-
schrift University, 1980.
20. Venker-van Haagen AJ, Boow J, Hartman W: Hereditary transmission of
laryngeal paralysis in Bouviers. JAAHA 17:75–76, 1981.
COMPENDIUM
21. O’Brien JA, Hendriks JC: Inherited laryngeal paralysis: Analysis in the husky
cross. Vet Q 8:301–302, 1986.
22. Shelton GD, Podell M, Poncelet L, et al: Inherited polyneuropathy in Leon-
berger dogs: A mixed or intermediate form of Charcot-Marie-Tooth disease?
Muscle & Nerve 27:471–477, 2003.
23. Salisbury KS, Forbes S, Blevins WE: Peritracheal abscess associated with tra-
cheal collapse and bilateral laryngeal paralysis in a dog. JAVMA 196:1273–
1275, 1990.
24. Gaynor AR, Shofer FS, Washabau RJ: Risk factors for acquired megaesopha-
gus in dogs. JAVMA 211:1406–1412, 1997.
25. O’Brien JA, Harvey CE, Kelly AM, Tucker JA: Neurogenic atrophy of the
laryngeal muscles of the dog. J Small Anim Pract 14:521–532, 1973.
26. Harvey HJ, Irby NL, Watrous BJ: Laryngeal paralysis in hypothyroid dogs, in
Kirk RW (ed): Current Veterinary Therapy VIII: Small Animal Practice.
Philadelphia, WB Saunders, 1983, pp 694–697.
27. Jaggy A, Oliver JE, Ferguson DC, et al: Neurological manifestations of
hypothyroidism: A retrospective study of 29 dogs. J Vet Intern Med 8:328–
336, 1994.
28. Holt D, Brockman D: Diagnosis and management of laryngeal disease of the
dog and cat. Vet Clin North Am 24:855–871, 1994.
29. Gross ME, Dodam JR, Pope ER, Jones BD: A comparison of thiopental,
propofol, and diazepam-ketamine anesthesia for evaluation of laryngeal func-
tion in dogs premedicated with butorphanol and glycopyrrolate. JAAHA
38:503–506, 2002.
30. Tobias K, Jackson AM, Harvey RC: Effects of doxapram HCl on laryngeal
function of normal dogs and dogs with naturally occurring laryngeal paraly-
sis. Vet Anesth Analg 31:258–263, 2004.
31. Radlinsky MG, Mason DE, Hodgson D: Transnasal laryngoscopy for the
diagnosis of laryngeal paralysis in dogs. JAAHA 40:211–215, 2004.
32. Rudorf HR, Barr FJ, Lane JG: The role of ultrasound in the assessment of
laryngeal paralysis in the dog. Vet Radiol Ultrasound 42(4):338–343, 2001.
33. Lussier B, Flanders JA, Erb HN: The effect of unilateral arytenoid lateralization
on rima glottidis area in canine cadaver larynges. Vet Surg 25:121–126, 1996.
34. Amis TC, Smith MM, Gaber CE, Kurpershock C: Upper airway obstruction
in canine laryngeal paralysis. Am J Vet Res 47(5):1007–1010, 1986.
35. Love S, Waterman AE, Lane JG: The assessment of corrective surgery for
canine laryngeal paralysis by blood gas analysis: A review of 35 cases. J Small
Anim Pract 28:597–604, 1987.
36. Hedlund CS: Surgery of the upper respiratory system, in Fossum TW (ed):
Small Animal Surgery. St Louis, Mosby, 1997, p 629.
37. Griffon DJ: Upper airway obstruction in cats: Diagnosis and treatment. Com-
pend Contin Educ Pract Vet 22(10):897–907, 2000.
38. Vrancken AF, van Schaik IN, Hughes RA, Notermans NC: Drug therapy for
chronic idiopathic axonal polyneuropathy. Cochrane Database Syst Rev
2:CD003456, 2004.
39. Gourley IM, Paul H, Gregory C: Castellated laryngofissure and vocal fold
resection for the treatment of laryngeal paralysis in the dog. JAVMA 182(10):
1084–1086, 1983.
40. Smith MM, Gourley IM, Kerpershoek CJ, Amis TC: Evaluation of a modi-
fied castellated laryngofissure for alleviation of upper airway obstruction in
dogs with laryngeal paralysis. JAVMA 188(11):1279–1283, 1986.
41. Greenfield CL, Walshaw R, Kumar K, et al: Neuromuscular pedicle graft for
restoration of arytenoid abductor function in dogs with experimentally
induced laryngeal hemiplegia. Am J Vet Res 49(8):1360–1366, 1988.
42. Hedlund CS, Tangner CH, Waldron DR, Hobson HP: Permanent tra-
cheostomy perioperative and long-term data from 34 cases. JAAHA 24:585–
591, 1988.
November 2005
 Laryngeal Paralysis: Pathophysiology, Diagnosis, and Surgical Repair CE 869

43. Petersen SW, Rosin E, Bjorling DE: Surgical options for laryngeal paralysis 4. A possible association exists between laryngeal
in dogs: A consideration of partial laryngectomy. Compend Contin Educ Pract paralysis and
Vet 13(10):1531–1539, 1991.
a. hypoadrenocorticism.
44. Griffiths LG, Sullivan M, Reid SWJ: A comparison of the effects of unilat- b. hyperadrenocorticism.
eral thyroarytenoid lateralization versus cricoarytenoid laryngoplasty on the
area of the rima glottidis and clinical outcome in dogs with laryngeal paraly-
c. hypothyroidism.
sis. Vet Surg 30:359–365, 2001. d. insulinoma.
45. Hardie EM, Kolata RJ, Stone EA, Steiss JE: Laryngeal paralysis in three
cats. JAVMA 179:879–882, 1981. 5. Which anesthetic(s) is expected to have the least
46. Rozanski EA, Stobie D: Laryngeal paralysis secondary to a cystic thyroid impact on laryngeal function?
adenoma in a cat. Feline Pract 23(6):6–7, 1995. a. thiopental
47. Schaer M, Zaki FA, Harvey HJ, O’Reilly WH: Laryngeal hemiplegia due to b. propofol
neoplasia of the vagus nerve in a cat. JAVMA 174(5):513–515, 1979. c. diazepam plus ketamine
48. Cribb AE: Laryngeal paralysis in a mature cat [correspondence]. Can Vet J d. All of the above have a similar effect on laryngeal
27:27, 1986. function.
49. Payne JT, Martin RA, Rigg DL: Abductor muscle prosthesis for correction of
laryngeal paralysis in 10 dogs and one cat. JAAHA 26(6):599–604, 1990. 6. Administering doxapram to a dog with laryngeal
50. White RN: Unilateral arytenoid lateralisation for the treatment of laryngeal paralysis would not be expected to cause
paralysis in four cats. J Small Anim Pract 35(9):455–458, 1994. _____________ during laryngeal examination.
51. Campbell D, Holmberg DL: Surgical treatment of laryngeal paralysis in a a. increased respiratory effort
cat. Can Vet J 25(11):414–416, 1984. b. increased arytenoid abduction
c. paradoxical arytenoid motion
d. glottic constriction
ARTICLE #4 CE TEST
This article qualifies for 2 contact hours of continuing CE 7. Which statement regarding laryngeal paralysis is
education credit from the Auburn University College of true?
Veterinary Medicine. Subscribers may purchase individual a. It is advisable to have an endotracheal tube ready
CE tests or sign up for our annual CE program. Those when performing transnasal laryngoscopy because
who wish to apply this credit to fulfill state relicensure dogs may experience severe glottic constriction and
requirements should consult their respective state require intubation during examination.
authorities regarding the applicability of this program. b. Ultrasonography of the larynx correlates poorly with
To participate, fill out the test form inserted at the end laryngeal function.
of this issue or take CE tests online and get real-time c. Inappropriate choice of anesthetic protocols could
scores at CompendiumVet.com. lead to incorrect diagnosis of laryngeal paralysis.
d. Hypothyroidism has been shown to cause laryngeal
1. Which has reportedly caused laryngeal paralysis paralysis.
in dogs?
a. idiopathic nerve degeneration 8. A common complication of partial arytenoidec-
b. postsurgical complication tomy is
c. neoplasia a. surgical repair failure.
d. all of the above b. uncontrollable hemorrhage.
c. epiglottic paralysis.
2. Lar yngeal paralysis occurs most often in d. laryngeal “webbing.”
___________ dogs.
a. old, large-breed 9. Sutures can be passed between the ____________
b. old, small-breed cartilages to perform arytenoid lateralization.
c. young, large-breed a. arytenoid and thyroid
d. young, small-breed b. thyroid and cricoid
c. arytenoid and cricoid
3. Laryngeal paralysis in the Bouvier des Flandres is d. a and c
inherited as an _____________ trait.
a. X-linked 10. The _____________ cartilage is cut in a “stepwise”
b. autosomal dominant fashion during castellated laryngofissure.
c. autosomal recessive a. cricoid c. arytenoid
d. none of the above b. thyroid d. epiglottis

November 2005 Test answers now available at CompendiumVet.com COMPENDIUM

Teknik Operasi
Laryngotomy
Varhan Dwiyan Indra 1809511044
Ferdy Olga Saputra 1809511050
Maharani Lisna Wulandari 1809511056
Kelas B
TERMINOLOGI INDIKASI

Operasi pada laring dengan cara ● Oedema

menginsisi dinding laring ● Peradangan pada laring
menggunakan laryngotome. ● Infeksi
Laryngotomy dilakukan ketika ● Benda asing
saluran respirasi hewan bagian ● Obstruksi laring
atas telah mengalami gangguan ● Collaps laring
seperti terhalang benda asing ● Gangguan pada epiglottis (sering batuk,
atau adanya obstruksi sehingga tersedak, atau sulit bernapas)
hewan tersebut menjadi sulit ● Penyayatan parsial pada langit-langit
bernafas. Operasi laryngotomy lunak
dapat bersifat permanen atau ● arytenoidectomy
sementara untuk membantu ● faring limfoid hiperplasia
aliran nafas. ● Dorsal Displacemnet langit-langit lunak
● laryngeal ventriculocordectomy
● pengangkatan kantung laring
● debarking
● laryngotomi parsial
● trakeotomi sementara untuk melindungi
jalan nafas selama penyembuhan.
ANESTESI
A. Sapi
– Sedasi xylazine HCL 0,1-0,2 mg/kg BB secara intramuscular
– anestesi infiltrasi lokal pada area laring (Lidocaine 2/cm) atau
– Lignocaine 15-25 ml per 2 cm subcutan.
– Atau dengan anestesi umum, anestesi inhalasi dengan Halotan
dengan posisi dorsal recumbency
B. Kuda
– premedikasi dengan 0,1mg/kg midazolam secara intravena
– anestesi ddengan2,2 mg/kg ketamin hidroklorida secara intravena.
anestesi dimaintain dengan pemberian halotan di dalam oksigen dan
diberikan secara inhalasi.
– hewan dibaringkan secara dorsal recumbency.
– Dapat juga dilakukan dalam keadaan hewan tersedasi berdiri (standing
sedated)
– dengan anestesi lokal pada daerah pengoperasian dengan
menggunakan phenylbutazone 3-6 mg/kg BB secara intravena.
 ANESTESI
C. Anjing dan Kucing
• thiopental secara intra vena 13,2-26,4 mg/kg BB.
• Pramedikasi dengan Acepromazine secara intramuskuler 0.01-0.05 mg/kg BB
• kemudian induksi dengan butorphanol 0.05 mg kg/BB secara Intra vena
• dikuti dengan pemeliharaan dengan isofluran secara inhalasi (1,5-2%).
▪ Penggunaan anestesi diatas memilki keunggulan tidak mengakibatkan
pergerakan pada laring.
• Ada beberapa pilihan anestesi lain yaitu:
▪ Propofol secara intavena
▪ Ketamine ditambah diazepam secara intravena
▪ acepromazine secara i.M ditambah thiopental seara IV
▪ Acepromazien secara i.M ditambah propofol secara IV
• Pada kucing cukup dengan menggunakan Ketamin dan Xylasin dengan pemberian
Atropin sebelumnya, dosis anastesi disesuaikan dengan jenis hewan, berat badan,
sediaan obat anastesi.
 PREOPERASI
Sebelum melakukan tindakan operasi terlebih dahulu dilakukan
persiapan operasi. Adapun persiapan yang dilakukan adalah:
• Persiapan alat atau instrument bedah
• Persiapan ruangan operasi
• Persiapan pasien
• Persiapan operator.
 OPERASI
1. Pendekatan Ventral Laryngotomy
Pendekatan ini memberikan pembukaan yang lebih baik untuk prosedur pada anjing kecil.
• Hewan diposisikan pada dorsal recumbency, dan diposisikan dengan baik ke meja operasi.
• Sayatan kulit bagian ventral dibuat pada laring melalui midline. Otot sternohyoideus dipisahkan dan ditarik ke
lateral dengan retraktor Gelpi. Membran krikotiroid dan tulang rawan tiroid di insisi pada garis tengah, dan
ujung-ujungnya ditarik dengan forceps Gelpi kecil untuk mengekspos tulang rawan arytenoid dan vocal fold.
• Setelah itu lakukan insisi pada mukosa corniculate, cuneiform, dan proses vokal dari satu arytenoid tulang
rawan. Setiap mukosa berlebihan yang dipotong, dan mukosa dijahit untuk mengurangi produksi jaringan
granulasi dan meningkatkan ukuran jalan udara.
• Penutupan mukosa yang dilakukan menggunakan benang absorbable (5-0 atau 6-0) dengan pola menerus.
Sayatan kartilago tiroid dijahit dengan benang non absorbable dan pola terputus yang tidak menembus lumen
laring untuk mencegah utama dari tepi tulang rawan. Jaringan subkutan di tutup dengan jahitan continuous dan
kulit ditutup dengan jahitan simple interrupted.
• Bersihkan dengan antiseptic dengan alcohol. Berikan antibiotic local dan sistemik pada akhir operasi.
 OPERASI
2. Laseralisasi Cartilage Arytenoid
• Hewan diberikan anastesi umum
• Hewan tersebut diposisikan dalam posisi lateral recumbency untuk melakukan lateralisasi unilateral, dan sayatan kulit
dibuat sepanjang ventral alur jugularis laring.
• Otot sternohyoid ditarik kembali bagian ventral untuk mengekspos aspek lateral tiroid dan tulang rawan krikoid.
• Laring diputar untuk mengekspos otot thyropharyngeal, yang ditranseksi pada tepi dorsocaudal dari tulang rawan
tiroid.
• Sayap (alae) tulang rawan tiroid ditarik ke lateral, dan persimpangan krikotiroid (krikotiroid junction) dilakukan
penorehan. Sayatan dari sendi krikotiroid memberikan eksposur yang lebih baik, tetapi tidak selalu dilakukan.
Transeksi mungkin mengurangi diameter dari glottidis rima setelah penarikan arytenoid.
• Otot cricoarytenoideus dorsalis atau bagian kiri dari jaringan fibrosa dilakukan incisi dan transeksi.
• Artikulasi Cricoarytenoid dipotong dari kaudal ke kranial dengan menggunakan gunting Metzenbaum.
• Tulang rawan arytenoid dijahit ke bagian caudo-dorsal kartilago krikoid dengan benang nonabsorbable dengan pola
jahitan terputus sederhana. Dalam pemilihan bahan benang untuk penjahitan, tidak boleh terlalu besar agar tidak
menganggu saluran pernafasan (contoh pada kucing menggunakan ukuran benang nonabsorbable 3-0 atau 4-0)
tulang rawan arytenoid hanya perlu dipertahankan dalam posisi dan stabil pada inspirasi.
• Luka ditutup dengan menjahit otot thyropharyngeal dengan pola terputus menggunakan benang absorable (cat gut 2 -
0)
• Dilanjutkan penjahitan dengan pola simple kontinue untuk menutup jaringan subkutan menggunakan benang
absorable (cat gut 2 -0)
• Kulit dijahit dengan pola terputus menggunakan benang nonabsorbable
• Bekas jahitan / daerah incisi diberikan providone iodin 10% dan dibalut dengan perban.
Gambar 1. Proses laryngotomi pada sapi
 PASCAOPERASI
Pascaoperasi meliputi pengobatan, perawatan, dan observasi. Setelah recovery,
daerah di insisi harus dibersihkan dengan larutan encer dari povidone-iodine atau
chlorhexidine dan dibalut dengan perban. Penggunaan selang untuk alat bantu
pernafasan juga dilakukan beberapa jam pasca operasi sehingga pemberian oksigen bisa
langsung menuju ke trachea.
Hewan diberi makan secara parenteral dengan infus selama masa perawatan. Bekas
incisi dari Laryngotomy dibersihkan 2 kali sehari selama 14 hari. Jahitan diambil setelah 12-
14 hari. Aplikasi Fenylbutason diberikan selama 3-5 hari setiap 24 jam. Gejala gangguan
pernafasan serta gangguan organ vital lain juga diamati. Lakukan juga pemberian
antibiotik untuk mencegah infeksi.
Antiinflamasi diberikan guna mencegah peradangan pada saluran pernafasan. Luka
operasi akan sembuh sekitar 1-2 minggu. Dan hewan dapat diberikan latihan maupun
pekerjaan setelah 2 minggu. Hindari lokasi berdebu terutama saat masa penyembuhan.
THANK YOU