Surgery? or not!

BREATHING PROBLEMS AND SURGERY FOR THESE

  an UPDATE!


by  Dr Tom Ahern BVSC MRCVS


An enormous amount of research has been carried out in recent years with regard to abnormal breathing in horses. The number of surgical techniques aimed at the management of these problems has also increased. Some of the conclusions and some useful hints for persons considering having a throat procedure performed on their horse are covered below. I have done this by answering some of the most commonly asked questions from racing persons worldwide.


First a brief anatomical look at the throat reveals 2 main areas that can ‘dysfunction’. The most often referred to is the ‘larynx’ which is the gate or opening at the top of the windpipe (trachea). The pipe or cave through which the air passes to get to the larynx is the ‘pharynx’ and the base of this is formed by the soft palate. In the past it was said that ‘laryngeal’ problems were the most common whilst more recently it has become widely accepted that ‘pharyngeal’ problems are significantly more prevalent. 


Q1)     Does a horse always make an abnormal noise when it has a breathing problem?

Ans) (i) With laryngeal problems Yes! ...particularly when the horse is working in a relaxed manner ( off the bit). This is always an ‘Inspiratory’ (breathing in) noise. It is usually described as a high pitched whistle and is most often ‘continuous’ whilst working.

          (ii) With pharyngeal problems , in particular DDSP (dorsal Displacement of The Soft Palate) quotes of from 33% to more recently 52% of horses diagnosed (on a treadmill ) as having this problem had no history of abnormal noises. Remember again that this is the most common breathing problem! This then means that when a horse returns from a disappointing workout or race and the question is asked “Did he make any noises?”  an answer of “No!” does not exclude abnormal breathing as the cause. Those that make noises can be inspiratory, expiratory, or mixtures of both.


Q2)     If a horse makes a noise does he have a problem?

ANS.) It depends very much on what structure or structures are responsible for the noise.

   It is interesting to consider the situation of  ‘an open window in a wild rain storm’. One hears an irritating clapping noise from the flapping blinds as wind and rain stream through the open window. In walks the ever aware butler who announces “I will fix the problem Sir!” at which he tears down the blinds. “Problem solved!”. ..........?????

On occasions breathing problems can be like this. Some noises fall within the category of ‘normal’ and others are commonly associated with airway dysfunction.


Q3)   With regard to noises (if apparent) what observations can I make to assist in the diagnosis of a particular problem ?

ANS.) (i) Is the noise made whilst breathing in (inspiratory) or out (expiratory) or both.

Note: When a horse is throwing his forelegs forward, he is breathing IN!

            (ii) Is it continuous or intermittent?

            (iii) Is it a roaring, whistling, gurgling, or just thick to raspy noise.

            (iv) Does it appear to be coming from his throat, nasal passages. or nostrils.

            (v) What intensity is it?  Can you here it from a furlong away?

            (vi) Is it more apparent when the horse is ‘on’ or ‘off’ the bit ? Pulling or not ?

            (vii) Does the horse appear to be holding its breath or doing anything else

                    untoward with its breathing ?


The answers to these questions should greatly assist your veterinarian along with allied tests (scoping and lower airway -lung checks)in diagnosing airway problems.


Q4)    Are there many different types of throat problems ?

ANS.)  Yes !     Around about 35 at last count. Some are variations on a theme and

           others are quite distinctly individual.


Q5)    Are there many different operations performed on horses throats ?

ANS.) Yes !    Again about 20 procedures at a quick count. It is with dismay that I too

            often hear trainers making reference to, and comparing results of, different ‘throat

            operations without being aware of the exact type of procedure performed. For

            example there are 11 different procedures for ‘palate problems’. So if your horse

            had a palate surgery... a bit change.. then what type ?


Q6)    Does throat surgery always or in fact ever ‘FIX’ or ‘eliminate’ the problem totally ?

ANS.) No !  (i) The larynx. After surgery the larynx is ‘never’ normal ! However the

           surgery may well render the horse able to compete successfully. Again different

           procedures approach the problem in different ways. One of the worlds foremost

           researchers in this area is an Australian, Ian Fulton BVSc , who hails from Victoria.

           Ian has developed a new procedure which looks to replace the damaged nerve

           in the larynx.

                      (ii) The pharynx. A number of conditions of the pharynx are regarded as ‘

           abnormalities’ e.g. entrapment of the epiglottis,  whilst the most common types

           such as DDSP, PI and dynamic pharyngeal collapse , whilst regarded as

           abnormal (or inappropriate) when they occur during exercise are all very ‘normal’

           occurrences whilst the horse is eating.

SO !... if we were to stop or  ‘fix’ DDSP (displacement of the soft palate) then the horse would be unable to eat. “It could be done!”  as I have often remarked to trainers, but you would need to have him nominated for a race soon after... i.e.before he starves to death!    So we don’t fix them with surgery . We do however aim to reduce the incidence or intensity of the particular problem.

Also and as important to understand just because a horse makes a noise after surgery does not necessarily mean that surgery has failed in its objective !  A horse may also make less noise after surgery than before and yet not improve a centimetre. i.e The butler removed the blinds!


Thus  “ Noises don’t stop horses running ! However asphyxiation or airway collapse does. And remember horses can asphyxiate silently !”.


Q7)     When do I get surgery performed ?

ANS.) The obvious answer is (i)When the horse is not performing up to realistic

             expectations... poor performance.

                                                      (ii) When other significant problems.. lameness..etc

             have been eliminated.

                                                      (iii) When some judgment can be made as to the horses

             innate ability. Usually the trainer / rider decision. And they are most often

             somewhere near the mark!

NB:- it is probably worth noting here the ‘occasional’ instance  where the horse is deemed “not worth spending the money on” according to Mr T. Rainer and yet 2 years later still a maiden owners are continuing to pay full rates?? Unfortunately common sense does not always prevail.

                                                      (iv) When your vet is able to convince him or herself that

              this is ‘most likely’ the problem ! In some cases such as grade 5 laryngeal hemiparesis (complete paralysis of one side of the larynx) we can be sure. But in many cases we are in the position of having to assume or extrapolate to some extent .

That is to say that what we see via the scope including during high speed treadmill tests is actually occurring in a race. Treadmills are a wonderful step up the ladder in diagnostic technology and I highly recommend their use, but they are still a ‘diagnostic aide’.

When we can finally get into both the mind and airway of the horse during that crucial last 600 to 800 meters of a race we will then be able to talk about indisputable diagnoses.


Q8)    What procedure do I have performed and by whom ?

ANS.)  This situation is no different to any other where you are seeking services for which you or your client are going to pay.  Thus your options / choices are..

                     (i) ‘One stop shop’.... use the skills available at your regular clinic or hospital.

                     (ii) ‘Shop around’ ...  ask others in the industry ..etc  as to who or with whom

                            have they had most success with this particular problem ?

Regardless of which approach you take it is important to ASK QUESTIONS. Such as..

                    (a) To the surgeon.. What Technique  or combination of

                           techniques are you using ?

                     (b) What are YOUR results with this technique ? NOT the practises, the institutions, not some overseas vet...etc ! They (other vets) are not doing the surgery and surgery is no different to any other skill in that  the results often vary dependent on the individual surgeons skills and experience . It may be that the surgeon is new to the technique, and yet the results may well be fantastic. It is still important that you as a consumer are made fully aware of the situation.


Q9)     What constitutes success ?

ANS.) Most horses present for surgery unable to complete either workouts or races...i.e. they experience ‘fatigue’ before the Winning post  / end of workout. The idea of surgery is in the main to transpose the onset of fatigue to ‘anywhere’, even one step past the post.

Once a horse is doing his best work ‘on the line’ it is reasonable to assume ‘normality’.


Another commonly touted measure is, Did he Win a race / races after surgery ?  As much as academics regularly argue the validity of this point it is not unreasonable given that not many trainers will go along with surgery if they don’t consider that the horse is at least capable of winning a race somewhere. Thus a reasonable number of horses should win after surgery. This then is a question you can ask of your surgeon. i.e. What percentage of his / her patients have Won or competed well after surgery? Horses may also win despite surgery and may improve after successful surgery but not enough to win.

            ASK!..... QUESTIONS!.. The vet will appreciate your interest in their work!


Q10)  What part does the trainer / jockey / track rider play in the success or lack of after surgery ?

ANS.) A GREAT DEAL ! Surgeons as was stated previously, cannot ‘Fix’ these

            problems completely i.e. return the throat to normal. Horses that have ‘Choked’ ... asphyxiated during work have experienced something akin to ‘nearly drowning’! They don’t forget quickly. “Horses have an ability to recall individual incidents, that is second only to the elephant” said Robert Miller DVM. I am sure anyone who has spent enough time around horses is well aware of this.  For this reason and several others the trainer / jockey..etc have ‘as much’ to do with the success or failure of a procedure as does the surgeon. Personally I have the greatest admiration for trainers who are prepared to battle the ‘equine body and mind’ under these circumstances. I hope I am also one of the first (where logistically possible) to congratulate the trainer on his / her success !

              

Q11 )       If the result isn’t good (after surgery) can anything else be done ?

ANS.) Yes and No ! The most important thing to realise is that your vet doesn’t have a ‘crystal ball’, so that if you don’t keep in touch then there is usually ‘nothing’ that can be done.  There may well be no further course of action and then it must be concluded that surgery failed to improve the situation  or at least significantly.

However there have been enough instances where further surgery, or the addition of another technique has made the difference between ‘success’ and ‘failure’. Medical protocols may also be of assistance.

Of course if you don’t keep in contact with your surgeon, even to tell him / her that “ it appears to have been a waste of time” then how can he / she be of any assistance?  I can still recall at least one instance where a trainer did ring just to let me know of my ‘failure’, and yet after a 10 minute conversation decided to give the horse one last try. The horse went on to win 25 races in 3 states !

At this stage it may also be an appropriate time to ask / shop around to see if any other ideas / approaches may be of use.


Q12)   Can horses have lung problems and throat problems at the same time ?

ANS.)  Absolutely ! ... as the old saying goes “the knee bones connected to the thigh bone...”.  A dysfunctioning throat can lead to abnormal pressures being applied to the lower airways and certainly whilst the soft palate is displaced dorsally contamination of the lower airway with oral material (from the mouth) is possible. Conversely lower airway disease can lead to increased overall airway negative pressures which can contribute to collapse of the upper airway. The important thing from the owners point of view is to make sure that both areas are being considered.


Q13)   Do young horses grow out of these problems ?

ANS.)  In some cases and for different reasons the problem can be temporary. It may however be a misconception to conclude that if the noise has gone, the problem has gone ! Performance i.e... ‘ability to get to the line’ is often a  more reliable guide as it is quite conceivable that at least a reasonable number of these young horses simply become ‘silent chokers’ or adopt an attitude of ‘not trying’ !  And why shouldn’t they ?  Who likes to drown?


Q13     Are these problems genetic ?

ANS.)  (i) Yes, in most but not all cases of laryngeal hemiplegia (laryngeal weakness).

             Therefore breeding from ‘severely’ affected animals is generally not

              recommended.

              (ii)No,  in all cases of pharyngeal dysfunction that I am aware of. The problem is

              common and may occur in families but is not inherited. The progeny of particular

              stallions may have a higher incidence of audible DDSP (palate problems). The

              only common denominator that I have noted is that these animals are usually         

              very fast off the mark ‘athletic’ and thus apply more pressure in a shorter space of

              time to their airways thus increasing the opportunity for airway collapse to occur.

             The plus is however that these are often amongst the best performers. They thus

             should not  be exclude from breeding programs under the misconception that

             they will necessarily pass on this problem.




HOOF NOTE.

A last but  also very important consideration is that of the possibility of a ‘unfairly biased opinion’.

From a veterinary standpoint I must unfortunately admit to in the past having been  guilty of just  this.  A fact of life is that trainers are very unlikely to seek opinion from, or in fact even make known to his /her regular veterinarian that a particular horse has had a procedure performed by someone else, if all goes well and good race form eventuates. The opposite unfortunately often does occur with surgical or procedure failure. I can still remember once receiving a rather  unpleasant fax from a colleague stating that he was only aware of one horse out of ‘all’ the horses that I had operated on in this particular State that had won a race and he felt that this had only won as a result of a change of trainer! ........( for this reason he wondered why I persisted with my work. Was I just taking money for nothing? ) Unfortunately at that particular time I knew of at least 10 horses in stables that he regularly attended that had had very successful outcomes.... but of course the trainers had not made him aware of this. Why should they? .....Oh yes! and that change to a more ‘suitable trainer’... again unbeknown to the vet this horse had had an ‘original procedure’ 3 years prior following which it had Won 11 races. The next  procedure.(prior to the change of trainer) was an ‘update’.

So if you want a useful (not biased) opinion on ‘any procedure’ then ask the veterinarian involved (and by all means ask for statistics , numbers...etc) or a trainer who has had enough experience (not 1 procedure) with this technique. Ask the vet for his / her results and make a judgment on their work and not somebody elses.


My advise with ‘ANY SURGICAL PROCEDURE’ is to ask as many questions as possible ,of the appropriate people, and at the same time shop around. This applies to most things in a consumer society.