Symposium on Respiratory Diseases

Upper Airway Obstruction

General Principles and Selected Conditions
in the Dog and Cat

D. N. Aron, D.V.M.,* and D. T. Crowe, D.V.M.,t

In few conditions are the benefits of optimal management and the risks
Of inappropriate action as apparent as they are in upper airway obstruction.
Many dogs and cats are uniquely susceptible to these disorders as a
consequence of several anatomic and physiologic factors, and although
severity of obstruction and rapidity of progression vary depending upon
cause and time of presentation, precipitous decompensation to critical
obstruction and/or respiratory failure is an ever-present possibility.
Crucial management decisions depend upon rapid assessment of the
approximate level of the airway affected and of the degree of respiratory
distress . In view of the difficulties involved in delivering anesthesia to and
securing the compromised airway of the distressed small animal patient,
the services of a well-informed veterinarian experienced in such manage-
ment are required in severe cases. Furthermore, all measures must be
carried out in a manner that does not upset the animal in order to avoid
exacerbating its condition. Appreciation of these factors, greater understand-
ing of the various distinct disorders, and advances in techniques of medical
and surgical care have substantially reduced resultant morbidity and mor-
tality.
This article presents an overview of the clinical features of upper
airway obstructive disorders and a more detailed discussion of certain
common conditions.

GENERAL APPROACH TO ACUtE UPPER AIRWAY DISTRESS

Level of Airway Involvement

Most patients with acute upper airway compromise that lead to
respiratory distress tend to present with stridor (high-pitched, noisy respi-

*Diplomate, American College of Veterinary Surgeons; Assistant Professor, Department of

Small Animal Medicine, University of Georgia College of Veterinary Medicine, Athens,
Georgia
tDiplomate, American College of Veterinary Surgeons; Assistant Professor, Department of
Small Animal Medicine, Athens, Georgia

Veterinary Clinics of North America Small Animal Practice-Vol. 15, No.5, September 1985 891
892 D. N . ARON AND D. T . CROWE

ration, particularly on inspiration), dyspnea, and mild to moderate increases

in respiratory rate and heart rate. Beyond this, there is considerable
variability among the presenting signs of the conditions. From a manage-
ment standpoint, the major causes can be divided conveniently into two
main categories: those involving supraglottic structures ("the brachycephalic
airway syndrome," laryngeal collapse) and those affecting the subglottic
areas (tracheal neoplasia, foreign-body aspiration). Table 1 depicts the major
similarities and differences between the two categories in terms of clinical
signs and symptoms.
The clinical signs also depend on the degree of functional stenosis of
the airway. Up to one half of the airway can be compromised without
obvious clinical signs; however, upon close inspection, an "obstructive
breathing pattern" frequently may be noted. This consists of a slow
inspiratory phase followed by a rapid expiratory phase. As the obstruction
progresses, the expiratory phase of ventilation may also be restricted and
prolonged.
Severity of Airway Compromise
Because studies such as laryngoscopy and bronchoscopy and radio-
graphs can prove hazardous, less precise clinical means of determining
severity of airway involvement must initially be relied upon. As a general
rule, stridor tends to worsen as obstruction increases; however, when
airway compromise becomes severe, air entry is so diminished that audible
sounds decrease. Cyanosis does not become evident until the Pa0 2 is very
low (less than 60); thus, it is a late sign. Further, dyspneic hypoxic dogs
and cats with cyanosis often display pale mucous membranes, a condition
that can easily be mistaken for anemia because paleness washes cyanosis to
a grayish color. Furthermore, anemia and hypoxia can coexist in a patient,
making interpretation difficult. Signs of agitation, anxiety or restlessness,
and tachycardia at rest are clinical indicators of hypoxia that demand swift
attention, for there is a fine line between compromised and life-threatening,
uncompromised airway obstruction. Although the interpretation of signs
may not always be accurate, Table 2 can be used to achieve a rough
estimation of the severity of airway compromise. If the patient has severe
symptoms in any one category, the patient is considered to be in severe
distress and should be treated accordingly.
Assessment Techniques
The major errors in the initial management of upper airway problems
are underestimation of distress, overzealous examination, and performance

Table I. Clinical Features of Acute Upper Airway Distress

SUPRAGLOTIIC
CLINICAL SIGNS DISORDERS SUBGLOTIIC DISORDERS

Stridor Quiet and wet Loud

Voice alteration Muffied and hoarse Hoarse
Dysphagia +
Cough +
Fever + +
UPPER AIRWAY OBSTRUCTION 893
Table 2. Estimation of Severity of Airway Compromise and/or Distress
SEVERE (DEATH IS
CLINICAL SIGNS MILD MODERATE IMMINENT)

Color Normal Normal Pale, dusky, or

cyanotic
Air entry Mild t Moderate t Severe t
State of consciousness Normal or Anxious , restless Delirious,
restless when when undisturbed obtunded, or
disturbed semicomatose
Retractions of oral Absent Occasionally present Present, with
commissure and generalized use of
cervical musculature accessory muscles

oflaboratory studies that disturb the animal, thereby worsening the patient's
condition and defeating therapeutic goals. Every effort should be made to
keep the patient calm and to maintain a sense of security. The patient
should be allowed to maintain the position that provides the most comfort
and should be restrained only minimally. Fast movements that might be
interpreted as threatening should be avoided. If distress is moderate to
severe or likely to be exacerbated by laboratory studies and radiographs,
these studies should be withheld and visualization of the oral cavity and
airway should be postponed until it can be done under controlled conditions.
The owner should be questioned about the chronology of the breathing
problem . Inquiries should be made concerning the mode of onset of the
breathing problem, signs, and symptoms, as well as the patient's previous
problems and other significant events.
Conducting most of the examination from a distance minimizes distur-
bance and enables more reliable observation by avoiding the increases in
heart rate and respiratory rate. The following are rapidly assessed from a
distance: pattern of breathing, patient posture, color of mucous membranes,
respiratory rate, audible sounds, and state of consciousness. The patient
can be aproached slowly to further assess the pulse, color, and heart and
lung sounds. Auscultation and gentle palpation of the cervical area as well
as percussion of the thoracic area should be performed for a complete
examination. If these diagnostic procedures make the condition worse, they
should be abandoned. Not only will they exacerbate the condition, but it
is likely that the information obtained will be unreliable. It is important to
note extreme unresponsive agitation or extreme depression , especially
when accompanied by pallor and/or cyanosis, for these are ominous signs.
If these signs are present or if the patient demonstrates postural preferences,
do not attempt to perform more than the above examination. Most partic-
ularly, do not attempt an oral examination without control of the airway,
because doing so may precipitate laryngeal spasms, massive vagal discharge,
and cardiopulmonary arrest.
After rapid assessment, the approximate degree of airway compromise
and level of involvement can be determined in order to select appropriate
initial therapeutic measures.
894 D. N. ARON AND D. T. CROWE

CONTROL OF AIRWAY DISTRESS

Management Guidelines for Patients in Mild Distress
The initial management of this patient is primarily a matter of environ-
mental control. It is essential to avoid stress by proceeding slowly, always
aware of the potential for a worsened condition. Perform a thorough physical
examination as long as the patient is comfortable. Stabilization involves
avoiding stress and keeping the patient cool. Infrequently, this patient may
require treatment with supplemental oxygen provided by an environmen-
tally controlled oxygen cage* or administered through a nasopharyngeal
catheter (see the article "Inhalation Therapy: Oxygen Administration,
Humidification, and Aerosol Therapy").
Sedation and/or analgesia may be necessary to avoid further stress.
Rarely, corticosteroids (0.5 to 2.0 mg per kg dexamethasone, intravenously)
may be required if airway edema appears to be uncontrollable. Because
stress of any kind can cause a severe crisis, the veterinarian must be
prepared for all possible events and should be equipped to perform
orotracheal intubation or an emergency tracheostomy. In most cases, the
patient in mild distress is often best stabilized for 24 hours in the hospital
environment before one considers definitive surgical treatment and to allow
for a properly planned postoperative period.
Management Guidelines for Patients in Moderate Distress
The management of this patient primarily involves environmental
control, keeping the patient calm, and administration of supplemental
oxygen. As with the mildly affected patient, avoidance of stress and a cool
environment are fundamental. Frequently, corticosteroids are administered
to these patients to lessen airway obstruction due to inflamed edematous
respiratory membranes. Administration of minimal dosages of tranquilizers
and/or analgesics helps to keep the patient calm and facilitates the exami-
nation of the patient and the administration of supplemental oxygen. Oxygen
can be provided by an environmentally controlled oxygen cage or a
nasopharyngeal catheter. If the patient progresses to severe respiratory
distress, orotracheal intubatjon or a tracheostomy may be necessary. When
possible, the condition of these patients should be modified to at least the
mild status for 24 hours before one considers definitive surgical repair.
Management G~idelines for Patients in Severe Distress
The management of this patient primarily involves the immediate
establishment of an adequate airway. If this patient presents or becomes
delirious and at the same time becomes frantic owing to "air hunger,"
intravenous sedatives must be given so that an airway can be atraumatically
secured to prevent laryngeal spasm and possible cardiopulmonary arrest.
In addition, when performing an orotracheal intubation, the use of a
laryngoscope greatly decreases laryngeal trauma and the amount of sedatives
required for the emergency procedure. If this patient presents or becomes
obtunded, an Ambu bagt or anesthetic machine and mask can be used to
deliver oxygen while the veterinarian prepares for orotracheal intubation
with an endotracheal tube. Extend the cervical area and pull the tongue
*Kirschner Intensive Care System. Hazleton Systems Inc., Aberdeen, Maryland.
tHope II Ambu Bag. Ohio Medical Products, Division of Airco Inc., Madison, Wisconsin.
UPPER AIRWAY OBSTRUCTION 895
out prior to application of the mask. Only rarely can an orotracheal
intubation not be performed, even with a smaller endotracheal tube. When
this is the case, a tracheostomy must be performed quickly in order to
secure an airway. Fortunately, the need for these "slash" tracheostomies is
rare; if it is required, however, one should not hesitate. After a patent
airway is ensured, the patient should be given supplemental oxygen, which
in itself will contribute to calming and cooling, correcting hypoxia, and
decreasing edema by stimulating vascular constriction. This patient should
receive antiedema doses of corticosteroids at the same time; it may also
require cooling and light sedation. Once the severe respiratory distress
becomes moderate or mild, supplemental oxygen is provided by an envi-
ronmentally controlled oxygen cage or a nasopharyngeal catheter. Definitive
surgical procedure(s) may be necessary to achieve patient stabilization,
particularly with the severe forms of respiratory distress caused by airway
obstructions or disruptions. When possible, however, patient stabilization
is preferred prior to definitive surgery or invasive diagnostic procedures
requiring general anesthesia. This decreases the patient's anesthetic risks,
particularly due to arrythmias, and continued airway compromise after
surgery becomes less of a threat.
Anesthetic Agents to Calm Patients and Facilitate Airway Control
Our preference is to use neuroleptanalgesics to calm the distressed
patient and equalize the distribution of blood flow to the lungs, preventing
secondary hypoxia and pulmonary edema. 12 By combining a narcotic anal-
gesic and a tranquilizer, one can use a reduced dose of each agent, which
will minimize the adverse effects of each agent but still achieve the desired
result. An additional advantage is that one can reverse the narcotic
component if required. Patients receiving a narcotic analgesic and a
tranquilizer should be premedicated with an anticholinergic agent such as
atropine or glycopyrrolate to minimize the bradycardic effects of the
neuroleptanalgesics. In addition, the anticholinergics inhibit the effects of
vagal stimulation resulting from manipulation of the glottic region. Vagal
stimulation in the face of hypoxia and/or increased sympathetic tone can
lead to rapidly induced ventricular asystole. 13 It is very important that
patients have the dosages adjusted to meet their particular needs, which
may oblige a dosage less than that recommended. Table 3 lists neurolep-
tanalgesic combinations and dosages usually required for safe therapeutic
sedation. The higher end of the dosage range, given intravenously, is
generally necessary to allow controlled tracheal intubation. Intramuscular
routes are less predictable and are generally used for maintenance of the
sedation. Occasionally some drugs have been found to be very effective for
sedation when used alone. These include diazepam, acetylpromazine, and
butorphenol.
Securing the airway of a frantic animal suffering from severe airway
distress can be challenging. We have been successful at passing an endo-
tracheal tube in these patients after giving intravenous diazepam at a dosage
of 0.275 mg per kg. If this dose of diazepam is insufficient, we titrate
intravenous oxymorphone to effect (0.1 mg per kg is drawn up). At these
dosages, the drugs have minimal adverse effects; the consequence of the
diazepam will be dissipated in 20 minutes , and the narcotic can be reversed.
896 D. N. ARON AND D. T. CROWE

Table 3. Recommended Dosage of Selected Neuroleptanalgesic Combinations*

NEUROLEPTANALGESIC DOC CAT

Fentanyl and droperidol 1 ml per 20-40 kg, IV, or Not recommended

(Innovar-Vet) 1 mg per 10-15 kg, IM
Oxymorphone and Acetylpromazine or Diazepam
Oxymorphone 0.05-0.2 mg per kg, IM or
(Numorphan) IV, up to maximum of 4
mg
Acetylpromazine 0. 02-0.1 mg per kg, IM or
(Acepromazine) IV, up to maximum of 3
mg
Diazepam (Valium) 2.5-5.0 mg total dose, IM
or IV
Meperidine and Acetylpromazine or Diazepam
Meperidine (Demerol)t 1.0-2.0 mg per kg, IM or
IV
Acetyl promazine 0. 02-0.1 mg per kg, IM or
IV, up to maximum of 3
mg
Diazepam 2.5-5.0 mg total dose, IM
or IV
Butorphenol and Acetylpromazine or Diazepam
Butorphenol (Torbutrol) 0.2-0.4 mg per kg, IM or
IV
Acetyl promazine 0. 2-0.1 mg per kg, IM or
IV, up to maximum of 3
mg
Diazepam 2.5-5.0 mg total dose, IM
or IV
*Neuroleptanalgesic combinations given intramuscularly should provide a calming effect
for 3 to 4 hours.
tif given intravenously, inject meperidine very slowly in small increments to avoid
profound hypotension and respiratory arrest.
0. 05-0.1 mg per kg, IM or
IV
0. 02-0.1 mg per kg, IM or
IV, up to maximum of 3
mg
2.5 mg total dose, IM or
IV
2.0 mg per kg, IM or IV
0.02-0.1 mg per kg, IM or
IV, up to maximum of 3
mg
2.5 mg total dose, IM or
IV
0.2-0.4 mg per kg, IM or
IV
0.2-0.1 mg per kg, IM or
IV, up to maximum of 3
mg
2.5 mg total dose, IM or
IV

For the distressed cat, we have safely imd effectively passed an endotracheal
tube by giving an intravenous combination ofketamine (5.5 mg per kg) and
diazepam (0.275 mg per kg). These cats begin to recover from the effect of
this combination in 10 to 20 minutes if normal renal function is present.
Temporary Tracheostomy
A "slash" tracheostomy is rarely required to save a life. It is necessary
only when an endotracheal tube cannot be placed and obstructive distress
is severe. Conversely, an elective temporary tracheostomy is frequently
performed when respiratory problems are anticipated in the postoperative
period following major upper airway surgery. In these patients, an endo-
tracheal tube is already in place and the procedure is not performed under
the emergency stress conditions that are present when a "slash" tracheos-
tomy is required.
The temporary tracheostomy (Fig. l) is performed under controlled
aseptic conditions with an endotracheal tube in place. The ventral surface
of the trachea at the level of the second, third, or fourth tracheal rings is
UPPER AIRWAY OBSTRUCTION 897

Figure 1. A, Before one performs a tracheostomy, one must position the patient in dorsal
recumbency with a sandbag under its neck and its forelimbs tied caudally. B, Transverse
tracheostomy with placement of stay sutures. C, Longitudinal ( "H") tracheostomy with
placement of stay sutures. D, Retraction of the stay sutures eases tube placement; these
sutures are left long to facilitate postoperative manipulation of the trachea. E, A few skin
sutures can be placed at the very ends of the incision, and a sterile gauze sponge can be used
to protect the wound. F, The tracheostomy tube is stabilized around the cervical area with
umbilical tape.
898 D. N. ARON AND D. T. CROWE

exposed by a midline incision and retraction of the paired sternohyoideus

muscles. One must stay caudal to the cricoid cartilage but cranial enough
so that the tube does not become occluded or pulled out of the trachea
upon movement of the neck. After isolating the trachea, two stabilizing
sutures are placed around tracheal rings in the proximity of the proposed
incision and left long to enable intraoperative and postoperative manipula-
tion of the trachea. We have achieved good results by incising the trachea
either transversely between adjacent tracheal rings or longitudinally across
tracheal rings. The transverse incision should not extend over more than
one third of the circumference of the trachea. Occasionally with the
transverse incision it is necessary to remove small portions of the tracheal
rings both cranial and caudal to the incision to accomodate the tracheostomy
tube. When performing the longitudinal tracheostomy, one should incise
across as few tracheal rings as necessary for tube introduction. To further
ease tube insertion with the longitudinal tracheostomy, transverse incisions
can be made proximally and distally to form an "H". With the longitudinal
incision, it is important that the cartilage flaps do not invert into the lumen
upon insertion of the tube. This problem can be prevented by placing stay
sutures on each flap to facilitate external traction when the tube is being
placed. With either technique, it is important to avoid disrupting the
tracheal anatomy any more than is absolutely necessary. The tracheal
incision can be spread with the stay sutures or a hemostat to ease the

Figure 2. Inversion of tracheal cartilage that occurred as a result of a longitudinal "H"

tracheostomy.
UPPER AIRWAY OI.lSTRUCTION 899
placement of the tracheostomy tube. The tube is stabilized around the
cervical area and the skin incision is left open to prevent the development
of subcutaneous emphysema or a few loosely applied skin sutures may be
placed at the very ends of the incision.
With the transverse tracheostomy, occasionally it is difficult to insert
a properly sized tube without being excessively traumatic or needing to
partially excise tracheal rings. The longitudinal tracheostomy, especially
combined with the cranial and caudal transverse incisions, :allows for easy
tube insertion, but inversion of cartilage must be prevented (Fig. 2). We
have had minimal postoperative problems with either method as long as
we executed careful atraumatic technique.
Care should be used in the selection of the tracheostomy tube. The
length of the tube is important, for one that is too long will frequently ride
on the ventral tracheal wall, causing ulceration or hemorrhage. A tube that
is too short tends to slip out of the trachea. As a guide, select a tube that
extends approximately 6 to 7 tracheal ring segments but less than 10
segments. One should select the largest tube that enters the trachea
comfortably. A tube three quarters of the diameter of the trachea is best.
A cuffed tracheostomy tube may be necessary when aspiration is a problem
or when the use of positive pressure is desired. Double-cuffed tubes using
low-pressure balloons or single-cuffed tubes using high-volume, low-pres-

A B

Figure 3. A, Two types of cuffed tracheostomy tubes currently recommended: Shiley

double cuff and Hi-Lo single cuff, high volume, low pressure (American Hospital Supply,
Division of American Hospital Supply Corporation, McGaw Park, Illinois). With either cuff
type, pressure necrosis of the trachea is minimized. B, Jackson double-lumen tracheostomy
tube. The outer tube and inner cannula are shown.
900 D . N. ARON AND D. T . CROWE

sure balloons (Fig. 3) are currently used rather than a single-cuffed tube
using a high-pressure balloon. The high-pressure balloons have caused
more problems with eventual tracheal stenosis following pressure necrosis.
Ideal pressure in the balloon cuff should be less than 20 to 25 em HP but
should provide reliable occlusion of the tracheal lumen when intermittent
positive-pressure ventilation is provided.
Single-lumen tracheostomy tubes are much more difficult to care for
in the postoperative period than are double-lumen tubes* (see Fig. 3). The
inner cannula of the double-lumen tube can be easily removed and cleaned
while keeping the outer tube in place. It is much more difficult to
completely clean the single-lumen tube without completely removing it
from the tracheostomy site; thus, the single-lumen tube is predisposed to
blockage, despite diligent cleaning efforts (Fig. 4). If a double-lumen tube
cannot be obtained, a single-lumen rubber or plastic tracheostomy tube
can be used. However, we recommend that the tube be removed and
cleaned periodically or exchanged for a clean tube.
The most important part of the tracheostomy operation is the postop-
erative care, which requires careful monitoring, diligence, and patience.
When possible, a single-lumen tracheostomy tube in a fresh tracheostomy
should be left in place 2 to 3 days before it is changed. By this time, a
permanent tract exists and there is little danger of being unable to reinsert

*Jackson Trachea Tube. American Hospital Supply, Division of American Animal Hospital
Supply Corporation, McGaw Park, Illinois.

Figure 4. Single-lumen tracheostomy tube removed from a 13-year-old male Cocker

Spaniel cross. Although the tube was being flushed and suctioned every 4 to 6 hours for 3
days, the tube became occluded. (Courtesy of Dr. J. P. Toombs.)
UPPER AIRWAY OBSTRUCTION 901
the tube. Changing a tube prior to this time can be facilitated by traction
on the two sutures inserted around the tracheal rings in the proximity of
the tracheostomy. This maneuver helps tremendously in preventing the
tracheal opening from being lost in the soft tissues of the neck. The inner
cannula of a double-lumen tracheostomy tube should be removed and
cleaned every few hours for the first 2 to 3 days . The frequency of cleaning
can be decreased the longer the tube remains (every 6 to 8 hours the next
3 to 4 days, and every 12 to 24 hours thereafter) .
Special humidification of inspired air is necessary to prevent tracheitis
and crust formation. An inexpensive vaporizer can be provided for this
purpose. For short-term situations, 5 to 10 ml of sterile saline solution can
be instilled through the tube every 3 to 4 hours. Furthermore, saline
solution is a good mucolytic, does not cause bronchospasm, and can be
used just prior to suctioning to help liquefY secretions for removal.
A suction unit is necessary for tracheostomy care. Sterile rubber or
polyurethane or polyvinyl chloride catheters with two distal openings or a
"whistle" tip and an air vent near the opposite end or a Y-connector should
be available and should only be used in the trachea. The two openings or
"whistle" tip is necessary to prevent the catheter from being sucked against
the tracheal wall, which will cause mucosal damage. The air vent or Y-
connector will allow the catheter tip to be inserted into the trachea to the
level of the carina without suction. Only during withdrawal is the open end
of the air vent or Y-connector occluded and suction applied. As the suction
is applied, the tube is slowly moved with a twisting motion to allow contact
of the catheter tip with as much luminal-mucosal surface as possible (Fig.
5). Suction should be maintained for only 15 seconds or less because it is

Figure 5. The sterile suction tube is placed (without applying suction) until resistance is
met. Frequently the tube will extend into a mainstem bronchus. As suction is applied, the
tube is slowly pulled out with a twisting motion to allow contact of the catheter tip with as
much luminal-mucosal surface as possible.
902 D . N. ARON AND D . T. CROWE

Table 4. Complications of Temporary Tracheostomy

PROBLEM CAUSE

Tracheal irritation Tube too large or too long

Tracheal necrosis Cuff used excessively; cuff pressure too
high
Tracheal stenosis Excessive cartilage excised from ventral
wall; secondary to tracheal irritation
and necrosis; inversion of cut tracheal
rings
Surgical injury of adjacent structures Technique careless; dissection carried
(that is, esophagus, recurrent laryngeal too lateral and deep to trachea
nerve)
Dislodgement of tube (could lead to Tube too short; poor patient observation
asphyxiation)
Aspiration and lung abscesses Careless postoperative management
Narrowing, occlusions of tube (could lead Cleaning, suctioning, and observation
to asphyxiation) not frequent enough (every 4-6 hr)
Tracheitis Humidification inadequate
Retained secretions; bronchopneumonia Tube not aspirated frequently enough;
inadequate humidification
Cervical emphysema Wound sutured too tightly around tube;
wound packed around tube
Cervical cellulitis Local wound care improper; bacterial
infection of wound
Persistent tracheocutaneous fistula Tube retained too long with
epithelialization of cannula tract

possible to precipitate hypoxia and cardiac arrest by prolonged suction.

Suctioning must be done often, especially during the first few days after
tracheostomy, because tracheobronchial secretions increase secondary to
tracheal irritation.
A tracheostomy tube should be left in place no longer than necessary.
As soon as the patient's condition permits, the size of the tracheostomy
tube should be reduced to a size to allow air to bypass the tube and pass
into the upper respiratory tract; this will help avoid physiologic dependence
on a large tube due to decreased respiratory resistance. Then the tube can
be plugged or simply removed, and the adequacy of the airway as well as
the ability to swallow and handle secretions can be determined. When
tubal occlusion (or the removed tube) has been tolerated for 8 to l2 hours,
the tube can be removed and the tracheocutaneous fistula left open.
Immediately after decannulation, the patient must be observed closely, and
means for re-establishing the airway must be readily available.
The complications of temporary tracheostomy can usually be avoided
if the surgery is performed carefully and diligent postoperative care is
carried out (Table 4). ·

BRACHYCEPHALIC AIRWAY SYNDROME

The breeds usually affected by brachycephalic airway syndrome include

the Bulldog, Boxer, Boston Terrier, Pug, Pekingese, Shih Tzus, and any
UPPER AIRWAY OBSTRUCTION 903

Figure 6. Relationship of the epiglottis and normal soft palate. The soft palate should just
overlap the open epiglottis. The normal soft palate extends to the caudal point of the palatine
tonsilar sinus (crypt) at the palatopharyngeal arch.

short-nosed dog or cat (such as Himalayan). These animals have abnormally

developed skulls, which distort the nasopharynx, and a poorly developed
horizontal width of the nares, which causes stenosis. These anatomic
abnormalities predispose the animals to upper airway obstruction, which
will possibly result in respiratory distress. The subsequent high degree of
negative pressure needed for adequate inspiration leads to thickening and
attenuation of the mucous membranes and elongation of the soft palate.
Eventually, these anatomic abnormalities and secondary changes can lead
to ventilatory distress. This is especially apparent during stress, increased
physical activity, and heat stress. Problems with the upper airway include
various gradations and combinations of stenotic nares, elongated soft palate,
eversion of laryngeal saccules, laryngeal collapse, laryngeal edema, and
hypoplastic trachea. The mucous membranes of the oropharynx, naso-
phraynx, and larynx can quickly become edematous and hypertrophied.
Animals that are stable and not experiencing serious distress can be
examined under neuroleptanalgesia or light thiamylal or thiopental anes-
thesia. Prior to examination, the patient can be premedicated with atropine
and preoxygenated for 5 to 10 minutes. Then the pharynx is examined for
the relationship between the soft palate and epiglottis. Normally, the soft
palate should just overlap the open epiglottis (Fig. 6). The rima glottis
should be observed for symmetry. The vocal folds and arytenoid cartilages
should be inspected for swelling and ability to abduct upon inspiration.
Small, whitish swellings in the ventral aspect of the glottis just cranial to
904 D . N. ARON AND D. T. CROWE

the vocal folds represent everted laryngeal saccules. 18 In addition, the

amount of mucous membrane thickening, swelling, and proliferation should
be assessed. Occasionally, suction is necessary to evaluate the anatomy and
function of the glottis because thick secretions could obstruct visualization.
When examining this region, it is important to have the animal sedated or
only lightly anesthetized and to avoid excessive traction on the tongue, if
one is to appraise laryngeal function correctly and not distort the normal
anatomy. Other aspects of the examination that require no anesthesia
include visualization of the nares for severity of stenosis, palpation of the
trachea for size and collapsibility, and attention to the amount of noise
generated with inspiration and expiration. Occasionally chest and cervical
radiographs will be required to evaluate the lower aspect of the upper
airway (trachea and bronchi). This is particularly important in the older
animal that may have developed secondary changes (that is, bronchiectasis,
tracheal collapse). Based on these examinations, the veterinarian should be
able to define the necessary surgical or conservative treatment and render
a prognosis.
Surgery is best scheduled for the same time as the examination. In
our experience and that of others, 9 the treatment and prognosis depend
primarily on the appearance and function of the larynx. Those animals
exhibiting laryngeal distortion (collapse) and dysfunction carry a poor
prognosis; a salvage procedure such as permanent tracheostomy 11 can be
considered. The prognosis is better for an animal with a relatively normal-
appearing and functioning larynx, even though concurrent problems such
as enlarged tonsils, everted saccules, and moderate laryngeal edema may
be present. For these patients, our primary therapy is to enlarge the
stenotic nares (Fig. 7), resect the redundant soft palate (Fig. 8), excise the
everted laryngeal saccules, and possibly perform a tonsillectomy. When the
soft palate and larynx must be surgically manipulated, premedication with
an antiedema dose of dexamethasone just prior to surgery will help to
reduce postoperative edema. If excessive postoperative edema is antici-
pated, placing a prophylactic temporary tracheostomy tube at this time is
highly recommended.
In our opinion, the stenotic nares can be pivotal in creating many of
the problems that develop in the brachycephalic patient. When stenotic
nares are present, we feel they should be corrected as soon as possible,
even in puppies 3 to 4 months old. This correction seems to make a big
difference in decreasing or even preventing further problems. When the
patient can breathe through its nose, then the elongated soft palate will
interfere less with inspiration, slowing down the cycle of tissue irritation,
swelling, and hypertrophy. When stenotic nares are present with or without
mild concurrent symptomatology and soft-tissue pathology, we recommend
an early conservative treatment consisting of resection of stenotic nares.

LARYNGEAL PARALYSIS

Laryngeal paralysis, a condition in which the vocal cords cannot be

properly abducted, can be either congenital or acquired. The congenital
UPPER AIRWAY OBSTRUCTION 905

Figure 7. A, Stenotic nares. B, A deep triangular wedge is cut from the caudal aspect of
the external nose. C, The wound edges are apposed with small absorbable or nonabsorbable
sutures. D, This simple technique is very effective in correcting stenotic nares.

form of the problem has been reported to occur frequently in the Bouvier
des Flanders breed 17 and less commonly in the Bull Terrier, Malamute,
and Siberian Husky. The onset of clinical signs occurs at 4 to 6 months of
age. As an acquired disorder, laryngeal paralysis has been noted most
frequently in medium to giant breeds of dogs. 14 • 15 The acquired disorder
has been reported to involve smaller breeds of dogs 5 and cats as well. 7 The
clinical condition usually has an insidious onset with intermittent episodes
of severe respiratory distress. In some cases, an underlying cause such as
trauma, lymphosarcoma, hypothyroidism, or neuromuscular disease can be
identified, but usually the cause is not determined.
The tentative diagnosis with both the congenital and acquired disease
is based on historical and physical findings compatible with laryngeal
obstruction. These animals do not usually exhibit respiratory distress at
rest, but as they become excited or exercise, the flaccid vocal folds obstruct
the rapid flow of air during inspiration. Definitive diagnosis is based on
direct visualization of laryngeal dysfunction, which consists of the failure of
the vocal folds to abduct and collapse of the glottis on inspiration. It is
necessary to realize that, with paralysis, the vocal folds will adduct slightly
upon inspiration and that this movement should not be interpreted as
normal. The examination can be conducted using neuroleptanalgesia or
during recovery from very light thiamylal or thiopental anesthesia.
906 D. N. ARON AND D. T. CROWE

Figure 8. A, The first step in correction of an overlong soft palate is the placement of
two curved Carmault forceps along the intended line of resection. B, The excessive tissue is
removed. C , The wound edges and Carmaults are oversewn with 3-0 nonabsorbable suture
in the manner shown. D, The Carmaults are removed while pulling on the end of each suture
to effect closure and hemostasis of the wound edge. E, The same suture is run in the opposite
direction to form a cruciate pattern. Finish by tying both suture ends on themselves.
UPPER AIRWAY OBSTRUCTION 907
Once the patient has been stabilized, surgical reconstruction of the
larynx to enlarge the glottis may be attempted. This can be accomplished
by one of several techniques or by a combination of them. The commonly
reported methods include vocal fold resection, arytenoid cartilage laterali-
zation, 10• 16 castellated laryngofissure and vocal fold resection, 6 or partial
laryngectomy. 8 For the cat, a vocal fold resection or partial and unilateral
arytenoidectomy is preferred; for the small dog, a castellation of the
laryngofissure and vocal fold resection are preferred. Unilateral partial
arytenoidectomy and vocal fold resection may also be effective.
Our first choice for the medium to large dog is to perform a laryngo-
plasty by placing a prosthetic suture from the cricoid cartilage to the
muscular process of the arytenoid cartilage (Fig. 9). The prosthetic suture
used is 0 to no. 2 monofilament nylon inserted into the cartilage with the
aid of a K or reverse cutting needle. The larynx is placed in a moderate
amount of abduction but not under excessive tension.
For congenital laryngeal paralysis, we place bilateral prosthetic sutures
staged 3 to 4 weeks apart. Our goal is to achieve an adequately open rima
glottis. As a rule of thumb, the width between the vocal folds should be at
least double the normal resting laryngeal inlet diameter. If the opening of
the rima glottis is considered inadequate after placement of the prosthetic
sutures, a conservative vocal fold resection can be performed concurrently.
This is accomplished by bilateral removal of the midsection vocal folds
without disturbing the vocal folds on their dorsal and ventral aspects. This
helps prevent obstructive scarring (webbing).
When treating acquired laryngeal paralysis, therapy for a correctable
underlying etiology certainly must be attempted prior to surgical interven-
tion. However, when the etiology is undetermined or therapy does not
improve the condition, palliative surgery is the only recourse. In our
experience with acquired laryngeal paralysis, both sides of the larynx have
been involved, but .one side is usually more flaccid than the other. We
have achieved good results in these animals with unilateral placement of
the suture prosthesis on the more severely affected side. With severe
bilateral laryngeal paralysis, we place bilateral prosthetic sutures staged 3
to 4 weeks apart. A vocal fold resection or conservative partial arytenoidec-
tomy with vocal fold resection can be performed concurrently or delayed.
However, we find this is usually not necessary unless an inadequate glottic
opening is created or symptoms persist. With the acquired disorder, the
older patients occasionally will have calcified, fixated laryngeal cartilages.
In our experience, those that have calcified laryngeal cartilages on preop-
erative radiographs are not candidates for the lateralization procedure.
Often in these patients the cartilages cannot be abducted with the prosthetic
sutures and thus require a relatively sizable partial laryngectomy. In these
cases, partial laryngectomy consists of a bilateral vocal fold resection and a
unilateral partial arytenoidectomy sufficient enough to adequately open the
glottis (Fig. 10). The use of a uterine biopsy punch* to take small "bites"
of the medial cartilage facilitates a clean and controlled partial arytenoidec-
tomy and vocal fold resection.
*Uterine Biopsy Punch. American V. Mueller, Division of American Animal Hospital
Supply Corporation, Chicago, Illinois.
908 D. N. ARON AND D. T. CROWE

Figure 9. Suture technique for palliation of laryngeal paralysis. A, The patient is placed
in lateral recumbency with a lateral incision over the trachea. Care is taken to avoid the
jugular vein and branches. B, Dissection is continued to the level of the laryngotrachea and
esophagus. A dissection plane is developed between the thyropharyngeal and cricopharyngeal
muscles. A finger is passed deep to these muscles to palpate the dorsal median ridge on the
cricoid cartilage and the dorsal edge of the lamina of the thyroid cartilage. A tube is passed
down the esophagus to positively identify its position. C, working under the thyropharyngeal
and cricopharyngeal muscles, the suture needle is "walked off" ~he caudal edge of the cricoid
cartilage and passed into the lamina of the cartilage at a lateral to medial position that is
halfWay between the dorsal median ridge of the cricoid cartilage and dorsal edge of the lamin<!
of the thyroid cartilage. The needle is passed into the cartilage while not penetrating the
m1.1cosa. It is essential to avoid esophageal tissue when passing this suture. D, The muscular
process of the arytenoid cartilage is palpated, and the suture is placed into this protuberance
in a mattress pattern. E, The suture is tied to open the glottis to the position desired. F, The
glottic opening prior to suture placement and after suture placement.
UPPER AIRWAY OBSTRUCTION 909

Figure 10. A, The larynx in a norrrial resting (intermediate) position. B, The appearance
of a paralyzed larynx. C, A partial laryngectomy being performed with a uterine biopsy punch.
D, Completed partial laryngectomy that consisted of a bilateral vocal-fold resection and a
unilateral partial arytenoidectomy. Note the tags of dorsal and ventral vocal fold, which are
left to avoid webbing.

Postoperatively, the animals receiving the suture prosthesis must be

carefully observed for several days and frequently fed small volumes of soft
food until normal deglutition is apparent. These measures, along with
staging the bilateral suture prosthesis, are considered important to avoid
aspiration. ln addition to the postoperative precautions mentioned, patients
requiring a sizable partial laryngectomy may also require a postoperative
tracheostomy tube .
Table 5 lists the disadvantages we have found iii various procedures
for the surgical palliation of laryngeal paralysis.

Table 5. Disadvantages of Palliative Surgical Procedures for Laryngeal Paralysis

PROCEDURE DISADVANTAGES

Vocal fold resection Recurrences; obstructive scarring; aspiration

Suture prosthesis
Castellated laryngofissure and
vocal fold resection
Partial laryngectomy
Cannot be performed when cartilages have ossified
and fixed; aspiration; more difficult in small
patient
Recurrences; obstructive scarring; disruptive to
normal anatomy; difficult to perform when
cartilages have ossified; aspiration; requires
postoperative tracheostomy
Recurrences; obstructive scarring; disruptive to
normal anatomy; aspiration; may require
postoperative tracheostomy
910 D. N. ARON AND D . T. CROWE

UPPER AIRWAY DISRUPTION OR OBSTRUCTION

Disruption or Obstruction Due to Trauma

Upper airway trauma due to penetrating wounds, choking injury from
collars, blunt traumas, or iatrogenic causes occurs frequently. The severity
of injury can range from partial to complete obstruction to small holes to
complete separation of the involved tube making up the upper airway. The
result of the penetrating injury depends on the direction and method of
perforation. Bites can result in much more damage than superficial inspec-
tion reveals, because of the shearing of tissue that occurs. Penetrating
wounds induced by a bullet can be variable depending on the distance and
kinetic energy of wounding. We feel that the dictum "explore all penetrating
injuries" is prudent. The type of injury associated with blunt trauma
depends on the magnitude of the force, anatomic structures directly affected
by the force vector, the angular versus frontal direction of the vector, the
position of the unyielding cervical spine at the time of injury, the age of
the patient, the rigidity versus pliability of the laryngotracheal cartilages,
and the density of the intervening soft tissues. Iatrogenic causes of trauma
can result from rough orotracheal intubation or airway surgery resulting in
obstruction, as can occur with vocal fold resection or partial laryngectomy.
The animal may or may not be presented in severe respiratory distress,
and stridor may or may not be a prominent clinical feature. When an
animal is presented in distress , establishing a patent airway should be a
first priority, which may necessitate intubation or a tracheostomy. In any
patient with trauma to the cervical region, cervical spine injury should be
suspected; manipulation should be done with care until neurologic and
radiographic examinations have been completed. Once the patient is stable,
it is imperative to check for the extent of injury.
A step-wise analysis of signs of injury to the respiratory and digestive
systems should be performed. The cervical area should be palpated for
tender areas, distortion of anatomy, displaced cartilage fragments, subcu-
taneous emphysema, and hematoma. Quantification of subcutaneous em-
physema may give clues to the location of disruptive injury. Massive
subcutaneous emphysema usually results from tears of the laryngotracheal
axis; the pharyngoesophagus is more likely to be the source of radiographic
cervical emphysema alone or minimal emphysema. Thoracic tracheal dis-
ruption or subcutaneous emphysema can result in development of pneu-
momediastinum and pneumothorax.
Laryngoscopy and radiography can be extremely valuable diagnostic
tools with trauma patients. Although laryngoscopy allows assessment of the
status of the larynx, radiographs contribute a great deal of information about
the spine and the presence of free air. In complete tracheal transection,
the tracheal air column is usually disrupted, although occasionally the
amount of free air can confuse the analysis of the picture. In cervical trachea
separation, the suprahyoid musculature can pull the hyoid cranially. Dye
studies such as tracheograms and esophagrams can be helpful and should
be considered in selected cases if the airway is stable. These studies may
formally identify the presence of extravasation or obstruction, and a side
and level can be sought on surgical exploration. With adequate irrigation,
UPPER AIRWAY OBSTRUCTION 911
local debridement, drainage, and antibiotic coverage, mediastinitis will not
be a problem when leakage of the contrast agent occurs.
Intubation of a false passage is a realistic possibility in patients with
laryngeal injuries and tracheal transection. If this is the case, a tracheostomy
may be necessary to achieve control of the airway. A ventral midline
cervical incision extending into a sternotomy may be required to locate a
completely disrupted airway. When the pretracheal fascia is opened,
respiratory decompensation may occur, requiring a rapid search for the
distal segment by digital exploration of the upper mediastinum. Once
found , an endotracheal tube is guided into the distal segment and a tracheal
anastomosis is performed. Tracheal tears of lesser magnitude can cause
severe emphysema. Open direct suture repair or tracheostomy caudal to
the lacerated segment is recommended to manage massive subcutaneous
emphysema of tracheal origin, but occasionally a small tear will seal without
incident.
At times, the site of the tracheal wound cannot be found during an
exploratory operation. In such a case, and when a tracheal wound is strongly
suspected, one can deflate the cuff of the endotracheal tube, fill the surgical
wound with sterile saline solution, and increase the airway pressure. This
maneuver will result in air bubbling at the site of the tracheal wound if
such a wound is present at the area of the surgical wound. This particular
procedure should be utilized both for the identification of the presence or
absence of a tracheal wound and after the repair of such a wound in order
to test whether or not the suture line is airtight. Tracheal wounds without
complete transection should first be debrided if the edges are irregular,
then repaired. When the trachea is completely severed, the wound edges
should be debrided if they are ragged, and the trachea sufficiently mobilized
proximally and distally so that the anastomosis can be done without tension.
With all perforation injuries, the tissues should be considered at least
contaminated or, more likely, infected. Adequate irrigation, debridement,
drainage, and antibiotic coverage are considered fundamental adjuncts to
definitive repair.
Trauma such as that induced by a choke-chain can fracture or dislocate
the hyoid apparatus and/or larynx, resulting in severe swelling of the tongue
and perilaryngeal tissues. Even with an intact trachea, fractures of the
laryngeal cartilages can allow the endotracheal tube to follow an extraluminal
course. The airway can be established with a tracheostomy tube, mucosal
tears sutured with absorbable sutures, and free cartilaginous or bony
fragments debrided. In our experience, the patient with cervical trauma
can get by without hyoid function, although they frequently need to be fed
by a pharyngostomy tube while swelling and dysphagia diminish. Last but
not least, when dealing with these injuries, it is mandatory that the integrity
of the esophagus be determined. Any disruption requires primary repair.
In general, with victims of cervical trauma, feeding through a nasogastric,
pharyngostomy, or gastrostomy tube has greatly enhanced their recovery.
Possible sequelae to upper airway injuries include laryngeal paralysis
or stenosis involving the larynx or trachea. Paralysis should be handled as
previously discussed, and stenosis should be managed by resection and
anastomosis.
912 D. N. ARON AND D . T. CROWE

Obstruction Due to Foreign Bodies

Foreign bodies that involve the upper airway are uncommon but can
cause upper airway obstruction when they lodge in the pharynx, larynx, or
trachea (Fig. ll). Large objects have a tendency to be situated at the carina.
An animal that has aspirated a foreign body can be sedated or lightly
anesthetized, then held upside down while compression of the abdomen or
thorax or vigorous shaking is performed to dislodge the object. If this is
unsuccessful, an airway can be established and a laryngoscopy or bronchos-
copy attempted to remove the object carefully with snares. If this is not
possible or is unsuccessful, a tracheotomy or lobar excision 4 will be required,
depending on the location of the foreign body.
Obstruction Due to Extraluminal Masses
Upper airway obstructions due to extraluminal masses occur more
frequently than do obstructions due to foreign bodies. The list of extralu-
minal causes of obstruction is long and includes the following: thyroid and
parathyroid tumors; enlargement of the mandibular, retropharyngeal, me-
diastinal, or prescapular lymph nodes due to infections; neoplasia such as
tonsilar carcinoma; or granuloma such as histoplasmosis or coccidoides;
retropharyngeal or peritracheal abscesses and cysts; and cranial mediastinal
masses, thymomas , esophageal tumors, or esophageal granulomas secondary
to Spirocerca lupi. These conditions should be considered when an animal
shows continued signs of respiratory distress, coughing, dyspnea, stridor,
and vomiting or regurgitation. They can be diagnosed by radiography, fine-

Figure ll. Lateral thoracic radiograph of an adult domestic shorthaired cat with a stone
lodged at the carina of the trachea.
 UPPER AIRWAY OBSTRUCTION 913
needle aspiration and cytology, laryngoscopy, or bronchoscopy. Treatment
depends on the diagnosis and prognosis.

Obstruction Due to Tumors of the Larynx and Trachea

Tumors of this region resulting in upper airway obstructive disease are
relatively uncommon in the dog and cat. Many tumor types, both benign
and malignant, have been reported to involve the larynx and trachea of the
dog; in the cat, laryngeal tumors are seen infrequently and tracheal tumors
are seen even less frequently. Affected animals are presented for progressive
respiratory distress, occasionally associated with cyanosis, collapse, and
syncope. Coughing and altered voice can be early or late clinical signs.
Radiography of the cervical and thoracic airway and lungs can aid in making
a presumptive diagnosis and prognosis . Only when the presumptive diag-
nosis is not obvious and the patient is stable should laryngoscopy and
bronchoscopy be performed to confirm the diagnosis . Frequently, tracheal
tumors in the dog can be surgically resected and the trachea anastomosed.
The cervical trachea or larynx is exposed by a ventral midline incision and
the thoracic trachea is exposed by a right-sided thoracotomy at the site of
the mass . In the dog, most of these tumors do not recur or metastasize.
Laryngeal tumors may require a local excision or total laryngectomy and
permanent tracheostomy (Fig. 12), but they carry a worse prognosis for
morbidity or mortality than those involving the trachea.

Figure 12. A 9-year-old spayed female Miniature Poodle with a total laryngectomy and
permanent tracheostomy. Surgery was necessary to remove an extensive mast cell tumor of
the larynx.
914 D. N. ARON AND D. T. CROWE

Tracheal Resection and Anastomosis

Surgical correction for upper airway obstruction or disruption due to
trauma, foreign bodies, extraluminal masses, and neoplasms frequently
involves tracheal resection and/or anastomosis. When performing a tracheal
resection and anastomosis to correct obstruction or disruptive problems,
anesthetic management can be challenging. A well thought-out, preplanned
technique that involves rapid induction, "balanced" maintenance of anes-
thesia, adequate preoperative and intraoperative oxygenation and ventila-
tion, and diligent postoperative monitoring is necessary in these physio-
logically compromised patients. 1
When executing a tracheal resection and anastomosis, one's primary
objective is to avoid stenosis and subsequent respiratory distress. To this
end, success depends on avoiding excessive tension at the suture line,
reducing the formation of granulation tissue, and preserving mucous flow.
Up to 17 to 23 tracheal rings can be removed in the dog when the trachea
is mobilized from surrounding tissue from the level of the cricoid cartilage
to the carina. Because of collateral circulation, maintenance of the cranial
thyroid artery and bronchoesophageal artery allows adequate perfusion and
tracheal viability. 2 Other tension-relieving procedures include flexion of the
neck and the use of tension-relieving sutures (Fig. 13). The trachea of older
patients is less mobile (elastic); therefore, to resect an equivalent amount
of trachea, more tension-relieving procedures will be required in the older
patient than in the young patient.
We separate and mobilize the trachea from surrounding tissue for most
of the cervical area, for anastomosis of the cervical trachea or most of the
thoracic area, and for anastomosis of the thoracic trachea. One must take
care to develop a dissection plane close to the trachea to avoid damaging
the recurrent laryngeal nerves. Tension "protector" sutures should be
placed any time tension appears to be playing a role or prophylactically in
older patients. After these measures, if further tension relief is assumed to
be necessary, the neck can be coapted in flexion for 7 days after surgery.
Reduction of granulation tissue formation is directly related to tech-
nique. Precise, tensionless anatomic reconstruction, nonreactive suture
material, gentle tissue handling, and the avoidance of infection will all
contribute to decreased granulation tissue upon healing. We prefer the
simplified split-cartilage technique of reconstruction, which maintains good
anatomic alignment. 11 When the split-cartilage technique cannot be accom-
plished (as in small patients), we prefer the annular ligament-cartilage
technique (Fig. 14). Monofilament nonreactive sutures such as nylon or
polypropylene with swaged-on needles are best. These sutures are placed
in a simple interrupted pattern. One need not avoid entering the lumen of
the trachea, but the knots should be tied on the outside.
Mucous flow can be maintained by precise anatomic alignment, de-
creasing tension, maintaining the recurrent laryngeal nerves, and decreasing
granulation tissue. Stenosis may occur, but it may not become clinically
apparent until many months after the surgery.
Some of the most challenging cases a veterinarian may have to deal
with involve the upper airway. However, through diligent effort and careful
UPPER AIRWAY OBSTRUCTION 915

Figure 13. Tension-relieving procedures for tracheal anastomosis. A, Freeing the trachea
from surrounding tissue. The dissection plane is developed on the trachea to avoid damage to
surrounding structures. B, Four tension-relieving sutures are equispaced around the trachea.
These sutures are placed around a ring above and a ring below the anastomatic site. C, The
neck is coapted in flexion to decrease tension on the trachea.
916 D. N. ARON AND D. T. CROWE

A B

Figure 14. A, The split-cartilage technique of tracheal anastomosis. The trachea is resected
by incising through cartilage rings. When performing the anastomosis, normal tracheal anatomy
is closely maintained. B, The annular ligament-cartilage technique of tracheal anastomosis.
The trachea is resected by incising the annular ligaments between cartilage rings. When
performing the anastomosis, maintenance of a normal anatomic relationship is more difficult
to achieve.

surgical technique, they can be some of the most rewarding and life-saving
as well.

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Contin. Ed., 5:738-750, 1983.
UPPER AIRWAY OBSTRUCTION 917
12. Johnson, R. A.: Cardiology: Heart failure. In Wilkins, E. W. (ed.): MGH Textbook of
Emergency Medicine. Baltimore, The Williams & Wilkins Co., 1979.
13. Muir, W.: Personal communication, 1976.
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(ed.): Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat. Edition
2. Philadelphia, W. B. Saunders Co., 1983.
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Department of Small Animal Medicine

College of Veterinary Medicine
University of Georgia
Athens, Georgia 30602