A spontaneous email from a subscriber
*The following information has been provided by Dr. Phil Zeltzman, a board-certified veterinary surgeon from Whitehall, Pennsylvania as a courtesy to goodnewsforpets readers. The following article is only for the sharing of knowledge and information; it is not intended to replace consultation of a veterinarian or other qualified pet care professional. To subscribe to his newsletter,here.
On Thanksgiving day, I received this very nice email from DK, a thankful reader in Pennsylvania (who is not a client of mine):
"Hi Dr. Zeltzman! I just wanted to tell you how much I enjoy your newsletter, and especially appreciate the one on laryngeal paralysis.
My girl, Hershey, had LP surgery (...) in January 2007 (...). She went back to her "normal" Labrador life after surgery, even enjoying swimming (it was more like wading at her age!), chasing the squirrels out of her yard, and even trying to catch a groundhog (...). She never got AP, and ended up dying of oral malignant melanoma 16 months after surgery (and 5 weeks short of her 14th birthday).
Again, thanks for the newsletter, and thanks for spending evenings and especially Thanksgiving writing and sending it to all of us."
Laryngeal paralysis is not a death sentence As promised, we continue our exploration of laryngeal paralysis or "lar par."
Friendly reminder for longtime and newer subscribers, including my Yahoo buddies: what follows is COPYRIGHTED.
What are the complications?
Some coughing is expected after surgery, typically after eating and mostly after drinking. That's a good thing, as it will hopefully prevent the dog from "swallowing the wrong way."
The voice will change, and barking may disappear (I always say that the dog will "bark like a seal"), although it is not considered a complication, just a consequence of surgery.
Failure of the sutures is a rare but severe complication. This is why we insist on confinement and peace and quiet after surgery.
Occasionally, the cartilage, rather than the sutures, is to blame. There are some rare cases where the cartilage that forms the larynx is diseased ("necrosis") and simply crumbles as the sutures are placed.
By far, the most common complication is Aspiration Pneumonia ("AP" as some call it). This is a type of pneumonia due to aspiration, or inhalation, of food or water... or saliva into the lungs. Most of the time, aspiration is due to vomiting or regurgitation of stomach contents.
Other rare complications include those seen in any surgery: infection, bleeding, redness, and at worst, death under anesthesia or after surgery. I would say that swelling is however common.
Failure of surgery is minimized by experience of the surgeon and following postop instructions at home, starting with strict rest.
And then, they're luck. Bad luck. We recently treated Sebastian, a beautiful Setter who suddenly died after surgery, for no obvious reason. I still have nightmares about it. It is probable that he had massive vomiting, or rather regurgitation, which we don't know how to prevent. A similar story very well may have happened to Penny, a Golden Retriever, who incidentally also had spleen cancer...
Of course, we tend to painfully remember the failures more than the successes...
What is the treatment for aspiration pneumonia?
First, aspiration pneumonia (or AP) needs to be caught early.
We look for 4 criteria: coughing, lethargy, poor appetite and a fever. If you ever suspect AP, time is of the essence. A vet should see the patient ASAP, listen to the lungs and take chest X-rays to confirm the diagnosis.
Treatment involves hospitalization, IV fluids, strong antibiotics, nebulization and coupage. You can find more information on coupage on my web site (under "Surgical topics") as well as a video.
To paraphrase our title, I have to insist:
Aspiration pneumonia is not a death sentence.
It can be successfully treated if caught and treated early.
What's new with Lar Par?
Treatment of LP has been pretty much the same for years. It's a very well established surgical technique. But I think that 4 noteworthy improvements have been recently suggested at the American College of Veterinary Surgeons Symposium.
1. A trick to confirm the diagnosis in questionable cases, is to inject a respiratory stimulant, doxapram (Dopram), during the exam of the larynx under sedation.
2.The research hasn't been published yet, but we now give patients an anti-vomiting drug called metoclopramide (Reglan), for life, after surgery. The hope is to decrease the risk of vomiting. Metoclopramide helps move food downward. It is cheap, and has few side effects. One possible side effect is hyperactivity. Ironically, Labs are the number breed with Lar Par, and many of them are kinda hyper to begin with! So far, we have not heard any complaints about using metoclopramide. One contra-indication may be patients with seizures, so another anti-vomiting drug should be used.
Other surgeons may use other drugs to combat vomiting or regurgitation, so I would suggest trusting your vet or surgeon. One drug recently mentioned is cisapride.
This is a new frontier for vets, as we trying to reduce the frequency of complications related to vomiting and regurgitation.
Similarly, we now give a slow IV drip of metoclopramide during anesthesia and surgery, and until the patient starts eating.
3. The old thought was "the bigger the opening, the more oxygen goes in" as we perform a tie back surgery. That's common sense.
Or is it?
Turns out that the bigger the opening, the higher the risk of aspiration pneumonia. So now, we try to compromise. We don't make the opening in the larynx too big, just enough for the patient to breathe comfortably. This is clearly art more than science, and you can see how experience comes into play.
What's the downside? The patient will likely have a noisier breathing, as air goes through a smaller opening. But again, if the patient can breathe comfortably, we don't care.
As I now tell my clients, "I don't treat noise, I treat dogs."
Hopefully that makes sense...
Now, other surgeons may have a different protocol -- again, trust them and their experience.
4. Lastly, we are progressively discovering that laryngeal paralysis may only be the tip of the iceberg in some dogs. Studies show that other muscles may be affected, for example in the legs, or in the esophagus (the tube between the mouth and the stomach). This may explain why treatment sometimes fails.
What do I need to do at home after surgery?
This will depends on your surgeon's recommendations. In our practice, we recommend:
. Strict rest for 2 months to allow healing with scar tissue.
. Soft food ("meat balls") for 2 weeks.
. Not too much water intake at once.
. Pain killers for 7 days.
. Antibiotics for 3-5 days.
. An anti-vomiting drug for life.
. Weight loss (these patients are often chubby) or weight control.
Long term, we recommend using a harness instead of a neck collar.
Some surgeons do not recommend swimming after surgery: the dog has a permanently open larynx, with no possibility of closing it off, should (s)he swallow water.There is therefore a risk of aspiration of dirty water at best, and drowning at worst.
Some people will disagree with that. I don't see why anyone would take a chance.
. Done by an experienced surgeon, Lar Par surgery truly improves the pet's quality of life. Clients often tell me after surgery that their (older) dog "acts like a puppy again." See DK's email above.
. Another one of my favorite quotes: We do Lar Par surgery to increase "quantity" of life, but mostly quality of life. Quality of life includes breathing comfortably.
. In most cases, results are good to excellent.
. However, any serious surgeon should have an honest discussion with you about the complications of Lar Par surgery.
My opinion has been beautifully expressed by a pet owner on the LP Yahoo group.It is so well written and so true, that I decided to share it with my readers. With permission, and with a few slight changes by myself, here it is.
LP is NOT a death sentence!
The following text was written by Terri G. in an effort to help allay the fears that all of us who are newly faced with laryngeal paralysis feel. (...) Thanks, Terri! If Boomer's legacy can be that you help even one person be less scared, that's a pretty good legacy for your boy to have.
"LP isn't a death sentence - it's treatable surgically, one way or another, it's fixable.
A tieback doesn't mean a dog will get aspiration pneumonia and die. The two are not immutably joined. Most tieback dogs do very well, some don't, most do.Dogs with regurgitation issues or esophageal issues need meds to control these, but the meds are there. There is most definitely a higher chance of aspiration in these dogs, but AP doesn't have to kill either if caught early and treated properly. I know this personally.
I'm writing this because I'm constantly struck by the fear of owners with LP dogs, their fear of a tieback, of AP, of death. I don't think that needs to be. I think if a dog can't breathe, the decision is clear cut. And I think with a good surgeon, we can go into this with confidence that it will be OK, that our dogs will have a good life, that should they get AP, we will deal with it. I don't want it to be such a gut wrenching decision. When I think of the diseases I've dealt with in my dogs (...), diseases we couldn't fix, a dog with a tieback doesn't look so scary.
And the guidelines are just that, guidelines, not absolutes. Not to panic about if not followed to the letter. All surgeons are different in their post op instructions, all dogs are different. This just shouldn't be so hard. (There are) dogs who are (alive) years out (after surgery). (...) People who (know) me know the hell I went through with my dog, the panic, and none of it was necessary. And he was an IBD/regurge dog, and he got AP, and he got well.
I guess in memory of my beloved Boomer, I'm asking that you not allow yourselves to be scared by anyone, by us, by vets, by anyone. With a dog who's healthy enough for a tieback, and in the hands of the right surgeon, it's the right thing to do. There are so very many of us who can attest to this. Please be positive and have confidence in your dog, your surgeon, and yourselves. It's not terminal cancer, or terminal heart disease, it's a fixable disease."
In Memory of Boomer
LP Yahoo group
A friendly reminder
Just in case I forgot to mention it before, please keep in mind before stealing the information provided here, that this newsletter is COPYRIGHTED.
Where can I read more about "Lar Par"?
It that a trick question? Of course, at drphilzeltzman.com under "Surgical Topics" where you can find more information on Lar Par, aspiration pneumonia, coupage and countless other topics.
Also at...Well, sorry, my newsletter software doesn't allow me to publish the address, so let's try this (of course with no spaces!):
http:// pets DOT groups DOT yahoo DOT com/group/LP
If is makes no sense, I apologize, you will find this link on my web site.
This is a "Yahoo group", dedicated to owners of dogs with Lar Par. It's a truly incredible resource, with a very supportive network of pet owners throughout the country and the world.
Let's end with a smile!
These dogs at the beach display happiness is its purest form.
This video from Hungary will take 3:30 minutes of your time.
Behaviorists might be interested in the "final words."