Interview with Dr. Sane: Brachycephalic Airway Syndrome

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The following is a deep-dive interview between Dr. Matthew Everett Miller (MEM) and Dr. Tracy Sane (TS) about brachycephalic airway surgery. For a quick overview on this condition, click here. This interview has been lightly edited for clarity.

MEM: Working with you in the clinic, I hear you mention this surgery, brachycephalic airway surgery, probably every day. Tell us what this surgery is and why it’s important.

TS: Some of the most popular dog breeds, namely Pugs, bulldogs and Boston terriers, suffer from a condition called brachycephalic (short skull) syndrome, in which there are congenital and developmental causes for respiratory difficulty. Oftentimes, we can surgically address these difficulties by removing barriers to more efficient and comfortable breathing for these dogs.

MEM: Specifically, what is it you do surgically to correct this issue?

TS: There are several anatomic components to brachycephalic airway syndrome, but not all are present in each brachycephalic dog. When you first look at the head of a bulldog, Pug, Boston terrier, or any other example of a brachycephalic dog, the first notable difference between them and, let’s say a Collie or Labrador or other long-nosed dog, is that the nostrils are stenotic, which means they tend not to flare on inhalation. In fact, they most often will close on inspiration, which limits the flow of air through the nasal passages a great deal.

MEM: Not exactly sound engineering.

TS: Well it isn’t. Try pinching off your nostrils and attempting to inhale through them. Doesn’t work. When you think of the nose of a Collie, there very clearly are canals or “pipelines” that air flows through. In brachycephalic dogs, this pipeline is usually obstructed by a redundant fold of skin called the alar fold.

MEM: So surgically…

TS: Surgically, this redundant skin fold is excised with the laser, approximating a more rounded, normal appearance versus collapsed or stenotic appearance of the nasal opening, thus eliminating one of the obstructions of air flow in these dogs. A principle of physics….if you double the diameter of a pipe you increase by a factor of sixteen the amount of air that can pass through it. That’s quite an improvement in air flow per breath. So already the dog is feeling better. And with the laser, there is no post-op bleeding from the surgery site and no annoying and itchy sutures to remove later. Repigmentation of the nose to it’s original color, pink, brown, or black, usually takes a month.

MEM: Once you’ve opened their nose up, what’s the next step?

TS: The second component of the syndrome, as we examine the back of the mouth, and by far the most audible difference in brachycephalics, is the elongated soft palate. If you were to use your index finger and touch the roof of your mouth as far back as physically possible, you’d be touching your soft palate. It is a soft fleshy 1/2” to 1” long flap of tissue that extends backward from the hard palate. The hard palate is the part of the mouth, just behind your upper teeth that provides shape to the oral cavity and partial support of the teeth. The soft palate extends backwards from there, and just meets or slightly overlaps with the opening to the windpipe, at least in “regular” dogs. In these “regular” dogs, the soft palate should not cause any obstruction to inhalation. It should only allow a free-flowing path for air to travel from the nose through to the larynx and lower airways, and function as a bridge to preventing aspiration during swallowing.

MEM: That’s not the case in the smush-faced dogs we see, though.

TS: No it’s not. In the brachycephalic, in almost 100% of the dogs, the soft palate extends so far backwards that is partially covers the doorway to the windpipe, which of course does cause an obstruction to ideal air flow. If we go back to the image of the upper airway as a pipe, the presence of an elongated soft palate is the equivalent of placing your index finger onto one end of that pipe. Not much air can get around it, or not near as much. Decreasing the diameter of a pipe in half, again decreases the amount of air that can flow through it by a factor of sixteen. It’s getting kind of hard to breath. With the laser, I trim the excessively long portion of the soft palate away, so that at most there is a one or two millimeter overlap with the epiglottis. I warn people that the dogs may even make more noise for a week or so until the soft palate heals, then the noise level usually diminishes a great deal. Keeping the animals quiet, and possibly sedated for the first week post-operatively is ideal. I also tell people that soft food is easier to swallow.

MEM: The nose is open, the windpipe is unobstructed. What’s next?

TS: A third component, present about fifty percent of the time in my experience, is the presence of enlarged tonsils. Normally, the tonsils of dogs sit well within two recesses in the throat called tonsillar crypts. Brachycephalic tonsils are often enlarged to two, three, even four times the normal size, thanks to chronic airway turbulence and subsequent inflammation. When you’re working with as little real estate as is found within the upper airway of some brachycephalics, this enlargement can be a significant impedance to air flow.

MEM: Do you always remove the tonsil if they’re enlarged?

TS: Tonsils are lymph nodes. Their job is to fight infection, so I don’t remove them reflexively. If they do appear to inhibit air flow by their size, then I excise them easily using the laser with minimal to no bleeding, either during or after surgery. Tonsillectomies are usually not necessary in the younger surgical cases as it does take time for the tonsils to be large enough to be of concern.

MEM: Nostrils, soft palate, tonsils. I understand there’s one more component to the surgery.

TS: The fourth component of brachycephalic syndrome that can be surgically improved upon is the presence of laryngeal saccules. These structures develop secondary to upper airway turbulence and are located immediately in front of the vocal folds within the larynx, or “voice box”. They are initially little flabby “sacks” that occlude the tracheal opening and over time become harder and more fibrotic, and of course obstructive by their presence to airflow. They are usually not present in the brachycephalic puppy but almost always present in the adult brachycephalic dog. When present, they are easily removed with an elongated curved tip surgical scissor.

MEM: For owners who think their pet might benefit from this surgery, what happens after the procedure? What should owners know?

TS: After the surgery, discharge instructions are usually as follows:

  1. No off-leash running for at least a week, or even better, two weeks. It will take this long for significant healing to take place. Too early a return to exercise can result in nosebleeds, and needless spikes in post-op pain levels from exertion. I’ve personally witnessed the distress the animals feel when allowed to return to running too soon. I can only imagine what it feels like to go running after nasal and throat surgery. Sure, you may be able to do it, but why subject your pet to that? Let them have a two week vacation with leash walks only. Better yet if you use a harness instead of a collar.
  2. Feed soft food for a week. I tell people to take canned food and make it in to little meatballs. Just how little depends on the size of the dog; ping pong balls, golf ball sized, little Italian wedding soup meatballs, you understand. Offer them maybe a half dozen of them for their first meal at home. Why meatballs? Because dogs tend to swallow them whole when presented with them. Less chewing means easier swallowing, which means less discomfort. Minimizing discomfort where possible is always a goal of surgery. I would keep the meatballs going for about five days. Most of the post-op inflammatory response has resolved by five days out and they can tolerate a traditionally-presented canned food meal.
  3. Give post-op meds even if they seem to feel fine because what we’re wanting is pain relief and suppression of the tendency for brachycephalic to regurgitate. The usual cocktail of drugs sent home are: a potent pain reliever (usually a narcotic) along with a couple of drugs to minimize regurgitation and vomiting, which can be a post-op complication when any upper airway surgery is performed. If you anticipate trouble with exercise restriction that first week home, we may add a light sedative.

MEM: Take-away points? Perhaps for someone who is on the fence about putting their pet through surgery?

TS: I always tell people that the goal of doing brachycephalic airway surgery is not to improve their pets appearance or to make them quieter necessarily, but to improve airflow and respiratory comfort. Ultimately this also prevents worst-case scenarios such as eventual irreversible laryngeal collapse, or heat stroke and possibly early death. If anyone has any remaining questions for me, please call. I do require a pre-operative physical exam before booking brachycephalic airway surgery.


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