Laryngeal Paralysis

Things Aren't Always the Way They Appear

Max is an old dog. He is the constant companion of Nancy, who works at home, and Jake, her husband. Max arrived at my office just before the New Year. Nancy and Jake explained that Max had been previously diagnosed with laryngeal paralysis.* They said that Max was coping well with this disorder of the respiratory system, but recently had begun to vomit, did not want to eat and would periodically pant and appear upset. Max was up and walking, but obviously not feeling well. He was thin and ‘lumpy’, like so many older dogs, he had many fatty masses all over his body. It was evident that he had peripheral nerve disease and that his laryngeal paralysis was advanced, but it looked like there was more going on.

Most dogs with ’decompenstated’ laryngeal paralysis present to the emergency room, struggling to breathe, not able to walk, loud respirations,  blue gums, high body temperatures , generally in dire straits. Max just stood there with pink gums and steady respirations. Although he might need surgery sometime soon, I felt he was presenting today for another, possibly related, problem. Max was admitted to the hospital, we took radiographs (x-rays), checked blood work, and most importantly observed Max closely. He did not have pneumonia; his blood work looked awfully good. Then we took him for a walk, a very short one, outside to urinate. When he returned it was obvious he was having difficulty breathing, but his gums were still pink. Standing, he extended his neck, stood very still and he took long slow breaths. Max looked like he was concentrating hard. As I watched, I began to appreciate that those long slow breaths were barely moving his chest. I sedated Max so I could look at his laryngeal folds and I was amazed when I saw those two doors essentially closed, not moving at all, just a slit of an opening between them. The tissue was not red or swollen like most dogs in this condition, but a very normal pink! Max had so successfully compensated for his difficulty; he had seemingly ‘thought’ this situation through, no panic or distress. He would very slowly breathe, like a person underwater with a straw, through that narrow airway no matter what. I thought this was amazing! Certainly, Max had managed to fool me; he definitely did need a laryngeal tie back, and soon. Max was placed on oxygen and did well through the night. In the morning he had his surgery and a few days later he returned home to his family.

One of the diagnostic tools that I, as a veterinarian (a doctor treating essentially mute patients), rely on heavily is my observational skills. In my estimation, clinical observation is the key to achieving an accurate diagnosis. It is in our nature as humans to begin cataloging and grouping our experiences and as clinicians we look for certain signs that are associated with particular diseases, fitting our patients into categories whenever possible. But sometimes we are surprised, nay humbled, by the unpredictability of living organisms, like Max. I remain amazed by how he appeared to have given his condition such careful attention that he had mastered it so capably. While other dogs would have had to be treated far earlier, Max had found a way to manage his illness.

I am constantly reminded how every day, with each patient and client, it is a new experience. The minute I forget, or become too self-absorbed, I receive a not too gentle reminder, like my experience with Max. Diagnosing and treating Max reminded me of how things can stay the same and yet be very different. You have to put yourself in the patient’s position, see things from their vantage point because, just like Max, each patient’s coping skills and their perspective is different. Every patient (yes even animals) comes with a different set of experiences that brought them to my examination room.

What I find interesting is this lesson is equally applicable to dealing with people. So many clients come to the hospital scared, anxious, and even angry. No one wants to be in the position of having a sick pet, seeing a family member ill, worried about expenses or outcome. Yet I tend to interpret the way they behave as an indication of the whole of their personality. That is way too judgmental. Just like Max, they have developed their reactions, their coping skills, based on events that I am unfamiliar with. Currently they may have additional factors that are influencing their choices that I cannot begin to understand. Maybe, in the future, I should apply the lesson Max has taught me and step back, observe closely, contemplate and use previous experiences, as well as, being open to new lessons, in order to figure out the right plan or the correct approach to the person before me. Maybe if we take a moment and avoid snap decisions about the people before us we can all be a little more successful.

 
*Laryngeal Paralysis is a dysfunction of the larynx (also called the voice box). The larynx sits at the juncture of the pharynx, esophagus and trachea, behind the soft palate. It consists of two ‘folds,’ they behave as doors on either side of the airway that allow air to move into the trachea and when they close they prevent food and saliva from going into the trachea. It provides very important protection for the trachea and lungs. The larynx allows us to make noise. In people it is the organ that allows us to speak, in dogs and cats it is what creates their voice, barking and mewing. Laryngeal paralysis is a dysfunction of those important folds or doors. The doors no longer work properly; they do not open and close as they should. As the condition progresses the doors close more and more, eventually cutting off the movement of air into the lungs. One of the first signs that an affected pet demonstrates is a change in their voice and a louder than normal pant. Owners may notice their pet coughing or choking more when eating and drinking. As time passes and the condition worsens, the patient has progressively more difficulty breathing and does not tolerate exercise. Patients are often presented to the emergency service because of acute respiratory distress. This happens after the dog has exercised or become excited, or possibly the pet has just gone from the cold to a warm house, or just started coughing. The vocal folds hit each other as the pet tries to breathe and they become inflamed (swollen and red) then the airway becomes even more occluded. Now the pet’s condition begins to spiral as it struggles even harder to breathe. Obviously, the situation becomes rapidly more life threatening. The potential of rapid decompensation for these patients underscores the importance of the veterinarian identifying the early stages of laryngeal paralysis and their educating the client as to how to manage their pets and what signs to watch for.

Laryngeal paralysis occurs as a result of a dysfunction of the peripheral nervous system. The nerve that makes the larynx work (makes the doors open and close) is the longest nerve in the body, so when the nerves of the body are diseased this is often the first nerve that demonstrates signs of not working. Diseases like Myasthenia Gravis and Hypothyroidism can also lead to laryngeal dysfunction. Often times, in older dogs, laryngeal paralysis is a sign of a degenerative nerve condition that we do not fully understand and does not have an effective treatment. Some animals have laryngeal paralysis as a result of a genetic defect. The treatment for laryngeal paralysis is either correction of the underlying illness or surgery. The surgery is called a laryngeal tie back and it involves tying one of the vocal folds (doors) back, out of the way so the airway can remain open. There are obvious draw backs to this procedure the most significant being an increased risk of aspiration pneumonia. This is why we only consider the surgery once the patient’s condition is so advanced we have no other choice than to tie the vocal fold back.

 

Posted on July 14, 2014
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