2013 resident abstractsfinal.3

IS GIRTH MORE IMPORTANT THAN LENGTH? EXPERIENCES WITH FOLDED FLAP
PALATOPLASTY FOR THE TREATMENT OF BRACHYCEPHALIC OBSTRUCTIVE AIRWAY
SYNDROME (BOAS).
Kat Crosse MA VetMB MANZCVS
Massey University Veterinary Teaching Hospital, Palmerston North, New Zealand
Introduction
Brachycephalic obstructive airway syndrome (BOAS) is multifactorial, with respiratory and gastrointestinal
aspects. There are anatomical and functional abnormalities that result in a range of clinical signs. The
components of the disease have traditionally been divided into primary and secondary features. The primary
features include elongated soft palate, stenotic nares and tracheal hypoplasia with secondary components
including everted laryngeal saccules and laryngeal collapse. A high prevalence of gastrointestinal disease in
brachycephalic dogs suggests that upper airway disease and gastro-oesophageal disease may influence each
other [1-3]. Recently, cross sectional imaging has highlighted further contributing factors to airway obstruction.
Increased thickness of the soft palate was the most significant difference in brachycephalic and dolichocephalic
breeds when comparing sagittal CT sections of the pharynx.[4] This excess depth of tissue obstructs the
pharynx in all phases of the respiratory cycle. Narrowing of the airway diameter due to rostral and caudal
aberrant turbinates will also increase airway resistance. [5,6] All of these changes to the dynamics of airflow
through the respiratory cycle result in excessive turbulence and increased effort, characteristic of the
brachycephalic condition.
Rhinoplasty, free edge staphylectomy and resection of everted laryngeal saccules are the most frequently
performed surgical procedures for the treatment of BOAS. However, none of these procedures address the
excessively thick soft palate obstructing the pharynx. In contrast, folded-flap palatoplasty (FFP) has been
designed to both shorten and reduce the bulk of the soft palate, treating more components of the airway
obstruction. Whilst this technique has gained favour among surgeons in Europe, details of the procedure
including outcomes have not been previously reported in Australasia.
Materials and Methods
Medical records of all dogs having undergone a folded-flap palatoplasty between June 2009 and March 2013
were reviewed. During this time folded-flap palatoplasty was chosen exclusively for the treatment of elongated
soft palate by all the individual surgeons working at Massey University Veterinary Teaching Hospital
(MUVTH). Recorded information included breed, age at surgery, presence of gastrointestinal disease,
requirement of temporary tracheostomy and additional surgical procedures (rhinoplasty, sacculectomy).
Following clinical examination the severity of respiratory clinical signs was graded according to the scale
established by Poncet et al.[2]. The nares were subjectively assessed by the attending clinician. The palate was
assessed for excessive length and the larynx for eversion of saccules or evidence of collapse. Thoracic
radiographs were then performed. In addition an extubated right lateral view of the head and neck was then
taken to assess the thickness of the soft palate and the obstruction to the nasopharynx. The surgical procedure
followed the description by Dupre and Findji[7], with the only alteration being the placement of stay sutures in
the free edge of the palate to facilitate rostral traction. An ovoid incision was made in the oral mucosa and the
palate resected within this outline to the level of the nasopharyngeal mucosa and submucosa. This resulted in
removal of the palatine muscles and palatine salivary tissue.
Figure: Diagram of the folded flap palatoplasty[7] - (used with permission of L. Findji) Initial recovery was performed in theatre with the opportunity to place a tracheostomy tube if needed. Post-
operative care included opiod analgesia, non-steroidal anti-inflammatories, omeprazole and tracheostomy tube
care if needed. Food was withheld overnight and soft meatballs fed the following morning. Dogs were re-
evaluated either at MUVTH or at the referring veterinarians and a follow-up standard questionnaire was
conducted with owners with a minimum interval of 4 weeks post-operatively. The questionnaire was performed
via telephone interview by one author. Grading was recorded preoperatively and at follow-up for respiratory and
gastrointestinal signs following guidelines set by Poncet et al[2].
Results
Eleven dogs underwent folded-flap palatoplasty at MUVTH between June 2009 and March 2013. Two dogs
were lost to follow-up. Seven dogs were male (64%) and 4 were female (36%). Age at the time of surgery
varied from 5 months to 6 years (mean 2.8 years, median 2 years). Four breeds were represented; English
bulldog (n=6, 55%), Staffordshire bull terrier (n=1, 9%), Pug (n=1, 9%) and French bulldog (n=3, 27%).
No intra-operative complications were encountered in any procedure. Haemorrhage was controlled with bi-polar
electrocautery and no excessive haemorrhage was reported.
Improvement in respiratory grade was noted by eight out of nine owners. One owner described improvements
but the decreased frequency of clinical signs was not enough to reduce the overall grade. The improvement in
respiratory grade was significant (P<0.001) between pre-operative and follow-up times. An improvement
trending to significance (P=0.06) was also seen in gastrointestinal grade. The owners described this
improvement being within the first two weeks (56%) or within one month (44%). 78% of owners described the
overall improvement as excellent, 11% as good and 11% as fair. All owners demonstrated given the outcome,
they would happily have the procedure performed again and would recommend the procedure to other owners in
the same position.
Discussion
Traditional techniques only act to shorten the palate to prevent laryngeal obstruction, whereas the folded-flap
allows removal of the nasopharyngeal and oropharyngeal fixed obstructions as well. The procedure therefore
addresses more components of airway obstruction than the free edge staphylectomy. The technique is
technically more challenging and surgical times are longer than with traditional staphylectomy [7]. Peri-
operative swelling associated with staphylectomy is thought to contribute to morbidity and mortality
immediately post-operatively, including the likelihood of tracheostomy tube placement. Steroidal anti-
inflammatories are commonly used to reduce this incidence[8]. Other means to reduce incidence of swelling
have been recommended. Reducing the use of electrocautery [9] and alternating the use of sharp dissection for
carbon dioxide lasers[10] have been proposed. In our series of cases, no steroids were used and bi-polar
electrocautery was used routinely. With the folded-flap palatoplasty, the cut edges and suture line are located
within the oral cavity, so any swelling is less clinically significant. Owner opinion of the difference in their pets
was comparable to other studies [1,7,11], with an excellent outcome reported in 78% of cases. The
perioperative mortality of the series at 0% compares well to other studies [1,7,12]. Not all dogs had the same
surgical treatment, e.g. stenotic nares correction and this heterogeneous nature of the population negates our
ability to form direct comparisons with regard to outcome. Studies following a larger cohort of cases with
defined follow-up times would be of benefit, however, for this small group we can conclude the procedure is
safe and associated with owner assessment of an excellent response to treatment.
1. Poncet, C., et al  Journal of Small Animal Practice, 2006. 47(3): 137 2. Poncet, C., et al  Journal of Small Animal Practice, 2006. 46(6):
273 3. Gorenstein, A., et al  Pediatric pulmonology, 2003. 36(4):330 4. Ginn, J.A., et al. J Am Anim Hosp Assoc, 2008. 44(5): 243 5.
Oechtering, T., et al.Tierärztliche Praxis Kleintiere, 2007. 3 6. Grand, J.G.et al. The Journal of small animal practice, 2011. 52(5):232 7.
Dupré, G.  Proceedings of the European College of Veterinary Surgeons Annual Meeting, Lyon, France. 2005 8. Tobias, K.M  Veterinary
surgery : small animal. 2012. 18. 9. Bright, R.  The Journal of the American Animal Hospital Association, 1983(19) Wykes, P.M.  Problems
in veterinary medicine, 1991. 3(2):188 10. Davidson, E.B., et al.  Journal of the American Veterinary Medical Association, 2001. 219(6):
776 11. Riecks, T.W.  JAVMA, 2007. 230(9):1324 12 Harvey, C  Journal American Animal Hospital Association, 1982.  

Source: http://surgery.anzcvs.org.au/surgery_assets/Science%20Week%202013/BOAS.pdf