Postoperative Care of the ENT Patient
British Small Animal Veterinary Congress 2008
Holly Smith, DAVN (Surgical), D32/33 VN
The Royal Veterinary College
North Mymms, Hatfield, Hertfordshire

The patients covered by this title can be very varied, from routine to unusual. For example there are several surgeries which are done as an elective, sometimes changing to an emergency procedure and there are the traumatic injuries to these areas which can often need greater care. To try to include as many postoperative treatments as possible, these notes have been divided into individual cases.

Laryngeal Paralysis

The patient presents with signs that vary in their degree of severity, which can mean an elective surgery or an emergency one done immediately:

 Changed bark

 Dyspnoea

 Increased respiratory noise

 Open-mouth breathing

 Cyanotic mucous membranes

 Collapse

The clinical signs and an examination of the larynx under light general anaesthesia diagnose the condition. Surgery commonly carried out is an arytenoid lateralisation.

Postoperative Care

These patients are often middle-aged to elderly dogs, stressed and barking. They need to be initially recovered within easy reach of oxygen, often staying in the theatre until almost fully awake. The need for oxygen is still important when returned to the ward, in case of further dyspnoea. Our cases will often go into the intensive care unit for the initial postoperative period, where nasal prongs can be used for oxygen supplementation if necessary.

When the dog has returned to the general surgical ward they may have to be very lightly sedated to stop continual barking that can lead to a breakdown in the surgery. Commonly used is acepromazine at a dose of 0.005-0.01 mg/kg, taking into consideration the age and health of the patient and consulting with the patient's clinician. Simple things like moving the dog to a quieter part of the ward, if possible, can also prove effective.

Because one side of the arytenoid cartilage has been tied back, the risk of aspiration pneumonia is increased greatly. Offering water in a bowl on a stand from a height or, initially, in a controlled manner, and no syringing of water into the patient, will reduce the risk. Feeding wet food, by hand and in balls will also go further in reducing the risk of aspiration pneumonia. These patients do not necessarily have to be hand fed for the rest of their lives, but should not be fed dry, dusty or flaky food, but should be kept on wet diets.

No collar and leads should be used on these patients as this is the area of the initial surgical wound; a harness will reduce the risk of any breakdown of the surgical procedure.

Brachycephalic Obstructive Airway Syndrome

As the title suggests, brachycephalic breeds are affected! Presenting signs may have been going on for some time, and escalating with age, weather conditions and the animal's weight (worse in overweight animals):

 Dyspnoea

 Exercise intolerance (especially hotter weather)

 Increased upper respiratory noise

 Open mouth breathing/very noisy

On admission some patients may only need cooling down to ease their breathing; worse cases will need oxygen as well. Surgery is carried out to try to improve the amount of room for air to pass into and out of the upper respiratory tract. The common problems are overlong soft palate, everted ventricles and stenotic nares. Therefore surgery will often be soft palate resection, removal of ventricles and wedge resection/alar fold resection.

Postoperative Care

Initial recovery until extubation should be done in the theatre or intensive care where oxygen is readily available. Extubation is usually left until the animal is almost awake and flow-by oxygen is given immediately after, until the patient can cope on room air. Re-intubation is always a possibility if dyspnoea develops. For this reason, having an intravenous anaesthetic agent, such as propofol, an appropriately sized endotracheal tube and a laryngoscope always with the patient is prudent, so that an airway can be secured. There may be oedema and swelling around the surgical site so a smaller endotracheal tube, compared to that used for surgery, may be an easier, quicker fit in an emergency. Suction is always useful to clear any saliva or blood, thus making intubation easier and sometimes eliminating the need for it at all. If an endotracheal tube cannot be passed, and the patient is deteriorating, an emergency tracheostomy may need to be carried out by the clinician/anaesthetist.

If oxygen is used for a longer period of the recovery time, it should be humidified to keep secretions loose and easily suctioned out or coughed up. Aspiration pneumonia is also a risk in these animals from saliva and blood.

Using harnesses instead of collars and leads is better for the postoperative patient. These patients can do very well immediately postoperatively or some go on to have a tracheostomy and need a high level of care for several days if not weeks!

Aspiration Pneumonia

Although this is not a surgical case, it is very commonly a postoperative complication of airway surgery. This can start with as little as a moist cough, but can escalate quickly, with more severe clinical signs:

 Dyspnoea

 Pyrexia

 Anorexia

 Malaise

 Cyanosis

 Orthopnoea

This condition can be fatal. Treatment is very intensive and time consuming but can be the difference between life and death for the patient and is where the role of the veterinary nurse is vitally important.

Treatment includes:

 Oxygen--nasal prongs/oxygen cage if necessary

 Nebulisation--with humidified oxygen

 Coupage--shaking/vibrating/positional drainage and movement

 Intravenous fluids

 Antibiotics (prescribed by clinician)

 Bronchodilators (prescribed by clinician)

 Assisted feeding--patient must be in sternal recumbency or standing

 Assist with giving/holding water--no syringing as this can lead to further aspiration

Nebulisation and coupage make a great deal of difference to the patient's comfort and speed of recovery. It can be carried out as often as every 1-2 hours in the worst cases, reducing to every 4 hours. A handheld nebuliser can be used in front of the animal's nose and mouth or a room humidifier can be used to 'steam up' the whole kennel.

Aspergillosis

This is a fungal infection of the frontal sinuses. This is a potentially zoonotic condition and gloves, apron and goggles must be worn. This is a very painful condition, which can be chronic. The clinical signs can vary in severity:

 Nasal discharge--unilateral or bilateral

 Mucopurulent discharge

 Changed pigmentation on the nose/ discolouration of nostrils

 Depression

 Anorexia

 Pain

This condition can be treated in more than one way:

 Flush frontal sinuses with clotrimazole, under general anaesthetic

 Sinusotomy and place anti-fungal cream directly into the frontal sinuses

 A rhinotomy to directly scrape out the fungal plaques and place tubes into the sinuses for flushing

The postoperative treatment will obviously differ depending on the way in which the disease has initially been treated by the clinician.

Flushing

Monitor recovery from general anaesthetic, being wary of aspiration of any fluid left in the nasopharyngeal area or mouth. This is a much less invasive way to treat the infection, with a shorter hospital stay. It can sometimes be less effective, especially in severe cases.

Cream

Monitor recovery from general anaesthesia, especially airway obstruction from any draining cream. There will be a lot of cream and blood oozing from the holes in the frontal sinuses, which can be gently wiped off, especially after the patient is awake, as it will be more painful. This treatment is very messy initially, but is still a less invasive treatment, with just the initial post-procedure discomfort for the patient. Any cream or blood that has oozed from the wounds should be cleaned off the animal's skin, so that it does not become sore. There may be some localised swelling around the wounds on the forehead. If the swelling is severe an ice pack can be used to reduce it and help with analgesia. The ice pack should always be covered with a wet towel to prevent ice burn. It can be left on for 10 minutes at a time, every 4 hours.

Rhinotomy

Monitor recovery from anaesthesia. The two tubes in the sinuses will need to be flushed twice a day with clotrimazole mixed with water, followed by air to ensure the mixture reaches the sinus. The water and clotrimazole mix is still quite thick and slimy, which can lead to the syringe dislodging from the tubes. Patients find this a very unusual, uncomfortable and often painful treatment, but it is very effective for treating aspergillosis. The treatment can also be messy. An Elizabethan collar must be fitted to prevent tubes being pulled out; this will need to be regularly cleaned. Also, the animal's neck needs to be checked daily for any sign of very wet, smelly, sore skin, which can become a nasty wet eczema.

Aspergillosis can be a very miserable infection for patients. They may have a reduced sense of smell, be very painful and depressed. It is often useful to feed before the treatment as it doesn't taste nice. Lots of 'TLC', cleaning/grooming and tempting to eat are necessary postoperatively.

Tracheal Collapse

This condition usually presents with a classic 'honking' type cough, especially with exercise or excitement. This condition can be severe, especially in overweight animals. Clinical signs include:

 Exercise intolerance

 Dyspnoea

 Cyanosis

 Syncope

Surgery to place tracheal ring prosthesis can be performed. Postoperative care for these patients is to keep them calm and quiet. Sedation may need to be used if the animal is particularly noisy or stressed. With the surgical wound on the ventral neck, a harness should be used instead of a lead.

This condition is not always suitable for surgery and one can try to manage it medically:

 Bronchodilators

 Cough suppressants

 Antibiotics

 Steroids

 Weight reduction in obese patients

 Reduced exercise and use of a harness

Tracheostomy Tube

A tracheostomy tube is often placed as an emergency procedure in patients with upper airway obstructions. This can be from an injury, too much soft tissue (certain breeds), swelling of upper respiratory tract due to surgery or injury. For whichever reason one is placed, either electively or as an emergency, the postoperative care is the same:

 Oxygen therapy--the oxygen should be humidified, either through a cage, bubble humidifier or by putting sterile saline down the tracheostomy tube first (0.25-5 ml saline, depending on the size of the patient).

 Regular cleaning--this must be strict! Use a tracheostomy tube with an inner sleeve, so a patent airway is still maintained via the outer tube during cleaning. Suction may be needed to clear the trachea. A suction catheter with a smaller diameter than that of the trachoestomy tube should be used, and suction applied as the catheter is being withdrawn. Pre-oxygenating the patient before cleaning is often needed.

 Always a risk of blockage.

 Sedation may be needed in an emergency to clear/reposition/replace the tracheostomy tube.

 Slow recovery with oxygen and continual observation for obstruction are needed.

Common complications that occur include:

 Occlusion--infrequent cleaning and inadequate observation.

 Bronchopneumonia--inadequate cleaning and suction.

 Tracheitis--care not taken with suction and/or not enough humidification when giving oxygen.

 Infection/cellulitis--poor handling/hygiene, gloves need to be worn and hand washing is imperative. It is important to remember wound care for the tracheostomy site.

The patient will most likely be on a covering course of antibiotics to prevent infection and cellulitis.

Total Ear Canal Ablation and Bulla Osteotomy

This surgery has usually been carried out as an end stage to ear disease and to prevent further pain and destruction of the ear from infection. Patients have often had a long history of ear problems and various treatments, so can be in pain and wary; although, after the initial discomfort of the surgery, this should be improved. This is not always the case, however!

The surgery involves removing the vertical and horizontal ear canal, to the bulla. A 'window' is then made in the bone of the bulla and it is cleaned and flushed out. The surrounding soft tissues are then sutured. Therefore, the patient is left with no opening to the ear. In severe cases, a Penrose drain may be placed.

This is a painful procedure, and postoperative care must involve good analgesia. This is imperative not only for patient comfort but also for handling, as cleaning the surgical site is needed.

Postoperative considerations are:

 Analgesia--opioids, pre-, peri- and postoperatively. Some patients may even require a morphine, lidocaine and ketamine constant rate infusion initially.

 Eye care--as a complication during surgery the facial nerve may be damaged and the blink reflex may be absent postoperatively. The affected eye will need to be regularly lubricated, at least every 4 hours.

 Wound care--there is often bleeding, which dries out and causes crusting around the wound. This needs to be soaked and gently cleaned off when the patient is comfortable enough and will allow it to be carried out. It may have to be done in more than one session if necessary.

 Skin care--an Elizabethan collar will need to be fitted. The skin under the chin must be checked daily to prevent wet, red and sore patches developing. This collar must be cleaned regularly. Clipping the area will also make it easier to keep dry and clean.

These patients usually recover well and a general improvement in their demeanour may be noticed as they are much more comfortable. It is worth making sure owners know that this procedure is likely to have caused their pet to be deaf, if the ear disease had not already, which may alter behaviour.

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Holly Smith, DAVN(Surgical), D32/33, VN
The Royal Veterinary College
Hatfield, Hertfordshire, UK


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