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Vol. 22, No.

9 September 2000

CE Refereed Peer Review

Upper Airway
FOCAL POINT
★ Predicting the cause of upper
Obstruction in Cats:
airway obstruction—based on
history and clinical signs—is less
reliable in cats than it is in dogs.
Pathogenesis and
KEY FACTS
Clinical Signs
University of Edinburgh
■ Chronic, nonprogressive stertor
following an upper respiratory Dominique J. Griffon, DVM, MS, MRCVS
tract infection in cats is
suggestive of nasopharyngeal
ABSTRACT: Nasopharyngeal polyps and foreign bodies are the most common nasopharyngeal
stenosis.
obstructions in cats, but a good understanding of other conditions allows for early recognition
and appropriate management. Abscesses, infection, stenosis, or neoplasia may obstruct the
■ Early signs of upper airway nasopharynx. Laryngeal obstruction may be caused by a variety of conditions such as granu-
obstruction in cats should be lomatous laryngitis, neoplasia, cysts, laryngospasm, and laryngeal paralysis. Extramural com-
recognized before cyanosis pression of the upper airway should also be considered. Clinical signs of upper airway ob-
develops. struction provide valuable information about the degree of airway compromise and the
anatomic compartment involved but are not specific for any particular disease process.
■ Although the clinical appearance
of granulomatous laryngitis is

U
similar to that of laryngeal pper airway obstruction in cats is a common and sometimes life-threat-
neoplasia, these conditions can ening condition. Early recognition of clinical signs, combined with ap-
lead to drastically different propriate diagnostic and therapeutic approaches, increases the chances
outcomes. of a successful outcome. This requires a good understanding of the pathogenesis
of upper airway obstruction as well as the options available to treat each condi-
■ Temporary and permanent tion. A thorough knowledge of the anatomy of this complex region is also cru-
laryngeal paralysis may result cial, especially if any surgical correction is undertaken.
from a variety of conditions. This article focuses on obstructive diseases affecting the nasopharynx, phar-
ynx, and larynx in cats and reviews the anatomy, pathogenesis, and clinical signs
associated with these conditions. The intent is to help clinicians establish a com-
plete list of differentials and guide them through the diagnostic approach of up-
per airway obstruction. A companion article will familiarize clinicians with un-
usual conditions and provide small animal surgeons with new information
regarding treatment options.

ANATOMY
The upper respiratory tract includes the nares, nasal passages, pharynx, larynx,
and cervical trachea. The pharynx can be divided into three areas: the orophar-
ynx, nasopharynx, and laryngopharynx (Figure 1). The oropharynx is ventral to
Compendium September 2000 Small Animal/Exotics

the soft palate, extending folds ventrally and the ary-


from the palatoglossal arches tenoid cartilages dorsally; it
rostrally to the base of the functions mainly in phona-
epiglottis caudally. Dorsal to tion and divides the laryngeal
the soft palate, the nasophar- passage into a rostral vestibule
ynx is located between the and a caudal infraglottic cavi-
choanae and the intrapharyn- ty. The aryepiglottic fold aris-
geal ostium.1 It connects the es from the lateral margin of
nasal cavity with the larynx the epiglottis on each side of
and contains the pharyngeal the vestibule in both species;
opening of the auditory tubes. it ends at the arytenoid carti-
The normal length of these lage in dogs and at the cricoid
openings measures 4 mm in Figure 1—Anatomy of the feline upper respiratory tract (1 cartilage in cats.
cats. 2 Caudally, the bound- = nasal passage; 2 = nasopharynx; 3 = opening of the audi- The innervation of the lar-
aries of the intrapharyngeal tory tube; 4 = soft palate; 5 = oropharynx; 6 = laryn- ynx is similar in dogs and cats.
opening (or ostium) are the gopharynx; 7 = hyoepiglotticus; 8 = epiglottic cartilage; 9 The cranial laryngeal nerves
caudal edge of the soft palate = epiglottis; 10 = thyroid cartilage; 11 = vestibular fold; originate from the vagus nerve
and the palatopharyngeal 12 = depression rostral to the vocal fold; 13 = vocal fold; at the level of the nodose gan-
arches. The laryngopharynx 14 = cricoid arch; 15 = cricoid lamina). (Illustration by glion and directly supply the
or caudal pharynx, which is Ian Lennox, Medical Illustration, University of Edinburgh, larynx. The internal branches
common to both the diges- United Kingdom) provide sensory innervation of
tive and respiratory tracts, ex- the laryngeal mucosa, whereas
tends from the intrapharyngeal opening to the rostral the external branches provide motor innervation to the
border of the esophagus. cricothyroideus muscle. The caudal (recurrent) laryngeal
The anatomy of the cartilages forming the larynx dif- nerves originate from the vagus nerve at the thoracic in-
fers slightly between dogs and cats. In both species, let and loop around the subclavian artery on the right
three unpaired cartilages (the epiglottis, cricoid, and and the ligamentum arteriosum on the left before re-
thyroid) and one pair of arytenoid cartilages form the turning to the larynx2; they innervate all of the laryngeal
larynx, but the shapes of the cartilages differ: The cor- muscles except the cricothyroideus.
niculate and cuneiform processes of the arytenoid carti-
lages found in dogs are absent in cats.2 In dogs, there is PATHOGENESIS
a small interarytenoid cartilage between the two ary- Nasopharyngeal Polyps
tenoid cartilages.2 In cats, however, the arytenoid carti- Nasopharyngeal polyps are a common cause of upper
lages are only connected by the transverse interary- airway obstruction in cats. Also called otopharyngeal or
tenoid ligament. Cats also lack a vestibular ligament, inflammatory polyps, the benign pedunculated growths
which in dogs extends from the floor of the thyroid are of uncertain origin. Polyps may originate from the
cartilage to the cuneiform process. Consequently, the mucosal lining of the middle ear, auditory tube, and
feline arytenoid cartilage is connected to the floor of nasopharynx, all of which are similar histologically.5,6
2
the larynx by the vocal ligament only. The laryngeal Although the exact etiology is unknown, chronic in-
muscles are similar in both species, with the exception flammation, infection, and congenital anomalies have
of the ventricularis muscle, which is present only in been proposed as possible causes.7 Polyps have been as-
dogs. In both species, the cricoarytenoid muscle is re- sociated with rhinitis and otitis resulting from various
sponsible for abduction of the arytenoid cartilages. bacterial and viral agents (e.g., calicivirus).8 It is unclear
The laryngeal cartilages and ligaments are covered by whether these infections are primary or secondary con-
a mucosa that forms the walls of the larynx. In dogs, ditions. Because nasopharyngeal polyps are more com-
the lateral ventricles open on each side of the larynx be- mon in cats younger than 3 years of age,9,10 a familial or
tween the vestibular fold cranially and the vocal folds congenital origin has also been suggested.11 No breed or
caudally. The vestibular folds or “false vocal folds” con- sex predisposition has been described.
tain the ventricularis muscle and vestibular ligament.
Cats lack laryngeal ventricles, and there is only a slight Nasopharyngeal Abscess
depression in front of the vocal folds. Vestibular folds Extension of otitis media may also result in a na-
are present, however, but they do not contain any mus- sopharyngeal abscess rather than a polyp.12 In these un-
cle or ligament.3,4 The glottis consists of the two vocal usual cases, the abscess is located near the opening of

NASOPHARYNX ■ ARYTENOID CARTILAGES ■ VESTIBULAR FOLDS ■ CALICIVIRUS


Small Animal/Exotics Compendium September 2000

the auditory tube, obstructing the nasopharynx. Na- mous cell carcinoma is a very invasive tumor, common-
sopharyngeal abscesses may also form secondary to for- ly extending into the soft palate and laryngopharynx.20
eign body migration.13 Primary laryngeal neoplasia in dogs and cats is rare.21,22
Fungal infection of the nasopharynx is usually sec- Benign tumors (e.g., rhabdomyomas) have been de-
ondary to cryptococcal rhinitis. However, atypical pre- scribed in dogs23 but not in cats. Lymphosarcoma and
sentations in which cats present with signs of nasopha- squamous cell carcinoma are the most common laryn-
ryngeal disease without rhinitis have been reported.14 In geal neoplasms reported in cats.24 Lymphosarcoma may
these cases, the mycosis arises from the caudal part of present as a mass or a diffuse thickening of the entire
the nasal passage and forms a polypoid cryptococcoma, larynx,22 whereas squamous cell carcinoma may spread
obstructing the nasopharynx. from the larynx into the pharynx and soft palate. Ade-
Myiasis occasionally occurs in the pharynx, most nocarcinoma, epidermoid carcinoma, and undifferenti-
commonly in the retropharyngeal tissues, but may also ated carcinoma have also been described.25–27 Laryngeal
involve the soft palate.15 Cuterebra larvae may be visual- adenocarcinomas have been reported to metastasize to
ized through a “breathing hole” in the mucosal surface the regional lymph nodes, lung, and spleen.28
or may be found following excision of the surrounding
granuloma. Laryngeal Paralysis
Idiopathic laryngeal paralysis is less common in cats
Nasopharyngeal Stenosis than it is in dogs. Other causes of laryngeal paralysis in
Nasopharyngeal stenosis is an unusual form of upper cats include congenital defects, generalized neuromus-
airway obstruction secondary to scar tissue formation cular dysfunction, trauma, and neoplasia.29 Unilateral
across the nasopharynx. Whereas choanal atresia is a hemiplegia has also been described in one cat with lym-
developmental failure of the posterior nasal cavity to phomatous infiltration of the vagus nerve.30 Damage to
communicate with the nasopharynx, nasopharyngeal the recurrent laryngeal nerves may result from wounds
stenosis is an acquired disease. In humans, nasopharyn- to the ventrolateral neck and may be associated with
geal stenosis is thought to develop secondary to muco- Horner’s syndrome if the cervical sympathetic trunk
sal ulcerations associated with infection, caustic burns, has been damaged concurrently.31 Mechanical compres-
or oropharyngeal surgery.16 This condition has also sion of the recurrent laryngeal nerve resulting from in-
been described in cats following upper respiratory tract flammatory swelling or neoplasia of adjacent structures
infection.17 The location of the stenosis along the na- may result in neuropraxia.32 Laryngeal paralysis has also
sopharynx is variable. Scar tissue may form across the been reported following surgery of the trachea, thyroid,
openings of the caudal nares into the nasopharynx, de- and ligation of patent ductus arteriosus.33 In these cas-
creasing their diameter from 5 mm to pinpoint size. es, inadvertent transection of the laryngeal recurrent
Adhesions may also form caudally, attaching the soft nerve results in permanent laryngeal paralysis. Howev-
palate to the dorsal wall of the nasopharynx. er, postoperative laryngeal paralysis caused by excessive
retraction may be only temporary. Respiratory distress
Brachycephalic Syndrome may be noted immediately after surgery, especially if
Brachycephalic syndrome is a rare condition that has upper airway edema is present. In other cases, the onset
been described in brachycephalic cats (e.g., Persian of clinical signs may be delayed by several days or even
breeds).18 The short skull conformation in these ani- weeks. Although this is difficult to explain, clinical
mals is associated with an elongated soft palate, distort- signs developed 38 days (median) after experimental bi-
ed nasopharynx, and short narrow nasal passages lead- lateral recurrent nerve transection in dogs.34
ing to stenotic nares. Brachycephalic syndrome may
result in laryngeal edema and eventually collapse of the Inflammatory Laryngeal Disease
larynx in dogs. In cats, little is known about the clinical Inflammatory laryngeal disease in dogs and cats tends
significance of this syndrome. Because of their seden- to be acute but rarely results in life-threatening respira-
tary nature, cats with stenotic nares may not have sig- tory obstruction.35 Trauma, infectious agents, foreign
nificant upper respiratory problems for several years.15 body penetration, and insect bites may cause transient
laryngeal inflammation and edema. 24,35,36 However,
Neoplasia granulomatous laryngitis has been reported to cause se-
Neoplasia of the nasopharynx usually originates from vere progressive upper airway obstruction in cats.35,37
the nasal passage or the oral cavity. Adenocarcinoma, The clinical appearance of this condition is very similar
squamous cell carcinoma, and lymphosarcoma are the to that of laryngeal neoplasia: Asymmetric nodular le-
most common nasal tumors in cats.19 Tonsillar squa- sions obstruct the rima glottidis (Figures 2 and 3). Granu-

MYIASIS ■ STENOTIC NARES ■ HORNER’S SYNDROME ■ GRANULOMATOUS LARYNGITIS


Compendium September 2000 Small Animal/Exotics

lomatous laryngitis is a rare but the vocal folds.42 A paralaryn-


well-recognized disease in hu- geal cyst, derived from the
mans and can result in voice primitive branchial clefts, had
changes, dyspnea, and cough- been reported previously.43
ing.38 In humans, granuloma-
tous laryngitis has been associ- Extramural Compression
ated with tuberculosis, syphilis, Inflammation, infection,
fungal infection, intubation, trauma, and neoplasms of
and chronic abuse of the vocal structures adjacent to the up-
cords38; an idiopathic form has per airway may also result in
also been recognized.38 The eti- extramural compression. This
ology of granulomatous laryn- may include conditions af-
gitis remains unknown in cats. Figure 2—Endoscopic view of the larynx of a cat with fecting the subcutaneous tis-
granulomatous laryngitis. Note the proliferative changes sue, muscle, salivary glands,
Laryngospasm obstructing the rima glottis. (From Tasker S, Foster DJ, and regional lymph nodes.
Laryngospasm, which usual- Corcoran BM, et al: Obstructive inflammatory laryngeal Salivary mucoceles and ranu-
ly results from manipulation of disease in three cats. J Feline Med Surg 1:53–59, 1999. las are much less common in
the larynx during oral admin- Reprinted with permission.) cats than in dogs.15 Trauma
istration of medications or tra- seems to be the precipitating
cheal intubation and extuba- factor.18 Salivary neoplasms,
tion under light anesthesia, of which adenocarcinoma is
occurs more commonly in cats the most common type, are
than in dogs.39 Spontaneous, unusual but tend to be ag-
intermittent spasmodic closure gressive.18 Enlargement of the
of the larynx has also been re- submandibular or retropha-
ported as a cause for unpro- ryngeal lymph nodes may
voked, recurrent episodes of also compress the upper air-
respiratory distress and inspi- way. Isolated lymphadenopa-
ratory stridor, starting sudden- thy may result from bacterial
ly and lasting a few seconds.15 (including mycobacterial) or
These cats were normal on phys- viral infection or lymphosar-
ical examination; a presump- Figure 3—Histopathology of the granulomatous tissue coma. Plexiform vasculopathy
tive diagnosis was based on (original magnification, ×400) shown in Figure 2. The of the retropharyngeal lymph
history and elimination of predominant cell type consists of macrophages. (From node (Figure 4) resulted in
other causes of upper airway Tasker S, Foster DJ, Corcoran BM, et al: Obstructive in- inspiratory stridor and dysp-
obstruction. The clinical signs flammatory laryngeal disease in three cats. J Feline Med nea in one cat.44 This unusual
were potentially attributed to Surg 1:53–59, 1999. Reprinted with permission.) but benign condition involves
direct contact between the la- capillary proliferation and at-
ryngeal mucosa and irritant materials (e.g., hair, gastric rophy of the lymphoid tissue. The pathogenesis of this
fluid).15 vascular transformation is unknown, although ischemic
necrosis of the node may play a role.
Upper Respiratory Tract Cysts
Upper respiratory tract cysts are unusual in humans CLINICAL SIGNS
and animals. These cystic lesions may arise within the Up to one half of the airway may be compromised
lumen (intraluminal), within the walls of the larynx before animals show obvious respiratory signs.45 The
(intramural), or adjacent to the larynx (paralaryngeal). severity of clinical signs then progresses with the degree
Laryngeal cysts may also be classified as epithelial, ton- of functional stenosis, eventually leading to cyanosis.
sillar, or oncocytic, depending on the type of cells Cyanosis is a late sign of respiratory distress because it
found within the lining of the cyst.40 Laryngeal cysts does not become noticeable until the arterial oxygen
have been well documented in the subepiglottic and pressure has dropped below 60 mm Hg. Because
dorsal pharyngeal regions of horses.41 An epithelial la- cyanosis is even harder to notice when the patient is
ryngeal cyst has recently been described in a cat, as a anemic, it is important to recognize early signs of upper
fluid-filled mass located near the ventral attachment of airway obstruction and to attend to patients before this

INSPIRATORY STRIDOR ■ SUBEPIGLOTTIC REGION ■ NEOPLASMS ■ CYANOSIS


Small Animal/Exotics Compendium September 2000

condition occurs. This is espe- expiratory phase is often noted.


cially true in cats because they As the obstruction progresses,
tend not to show such obvious the expiratory phase may also
signs of mild respiratory diffi- be restricted and prolonged.45
culty but will decompensate Stridor is a soft and rasping
faster than dogs once they be- noise heard during inspiration
come dyspneic. in animals with mild laryngeal
Although clinical signs are obstruction. As severity pro-
variable and upper airway dis- gresses, stridor turns into a
eases may affect several regions, loud, high-pitched noise no-
localization of the level of ob- ticed during both respiratory
struction is often possible. For phases. Loss or change of voice
example, nasal and nasopha- Figure 4—Plexiform vascularization of a retropharyngeal is more commonly associated
lymph node causes extramural obstruction of the larynx
ryngeal diseases are commonly in a cat. Surgical excision of the encapsulated mass is cura- with neoplasia than with in-
associated with stertor, which is tive. flammation of the vocal folds.24
a snorting or snoring sound It may, however, also be related
emanating from the pharynx to laryngeal paralysis.33
and nasopharynx. Nasal dis- Coughing is a sign of mu-
charge and sneezing are incon- cosal irritation and may also be
sistent signs of nasal diseases. associated with laryngeal disease.24
The absence of airflow through A dry cough may be associated
the nasal passage can be diag- with laryngeal paralysis, neoplasia,
nosed by immobilization of a or granulomatous inflammation.
feather or lack of condensation However, it is also a common
on a cold slide in front of each sign of subepiglottic disorders.45
nostril. Open-mouth breathing Although diagnosing the level
will alleviate signs of upper air- of obstruction may be difficult,
way obstruction if the disease determining the nature of the
process has not extended into disease is even more challeng-
the oropharynx (Figure 5). Phar- ing. Because no one sign indi-
yngeal disorders may result in a Figure 5—Open-mouth breathing in a cat with na- cates a particular disease pro-
combination of respiratory and sopharyngeal stenosis. cess, history and clinical signs
alimentary signs (e.g., anorexia, can only help prioritize the list
swallowing disorders). De- of differentials.
pending on their size and location, nasopharyngeal
polyps may result in chronic, progressive alimentary, ACKNOWLEDGMENTS
auricular, and/or respiratory signs. Respiratory signs The author thanks Ian Lennox from Medical Illustra-
range from sneezing, nasal discharge, and stertor to stri- tion and Dr. D. A. Gunn-Moore from Feline Internal
dor and dyspnea. Other common signs include dyspha- Medicine, University of Edinburgh, United Kingdom.
gia and otorrhea.10 Head tilt and nystagmus are unusual
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68 The
COMPENDIUM
COLLECTION
Anim Pract 24:855–871, 1994.
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flammatory laryngeal disease in three cats. J Feline Med Surg
1:53–59, 1999.
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46. Aron DN, Crowe DT: Upper airway obstruction: General Dr. Griffon is affiliated with the Department of Small Ani-
principles and selected conditions in the dog and cat. Vet mal Surgery, Hospital for Small Animals, University of Ed-
Clin North Am Small Anim Pract 15(5):891–917, 1985. inburgh, United Kingdom. She is a Diplomate of the Amer-
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48. Griffon DJ, Tasker S: Use of a mucosal advancement flap