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Respiratory disease is common in guinea pigs (Cavia porcellus). As obligate nasal breathers, disease of the upper airway can result in significant dyspnea. Nasopharyngeal stenosis is defined as a luminal narrowing of the nasopharynx, which extends from the choana to the caudal margin of the soft palate. This condition can be acquired or congenital and has been diagnosed in other species. However, nasopharyngeal stenosis has not been previously described in guinea pigs. Four guinea pigs were presented with chronic, recurrent upper respiratory signs including stertor, oculonasal discharge, tachypnea, and dyspnea. All four animals had signs suggestive of upper respiratory tract disease on examination. Nasopharyngeal stenosis was identified at the rostral aspect of the nasopharynx at the level of the choana via computed tomography (CT) in all cases. Otitis media was also present in three of the four cases. Antibiotic therapy was instituted for all animals. Two of the four guinea pigs were treated with prednisolone and two were treated with meloxicam to control associated inflammation. One animal died 2 months after diagnosis due to complications from severe otitis media. One individual was euthanized due to progressive disease after a year and a half of treatment. One guinea pig was lost to follow up after 6 months. The remaining guinea pig was alive at the time this case series was written (11 months after initial diagnosis) but continues to have signs of upper airway disease. Nasopharyngeal stenosis is an important differential diagnosis for persistent upper respiratory signs in guinea pigs. CT was diagnostic in all cases, identifying nasopharyngeal stenosis at the level of the choana, and allowed identification of comorbidities (otitis media and rhinitis). Medical management resulted in survival times from 2 months to a year and a half following diagnosis. Further investigation into minimally invasive interventions such as balloon dilation and stent placement are warranted for future cases.

Summary A 10-year-old male entire Cavalier King Charles Spaniel was referred for investigation of frequent episodes of transient loss of consciousness during periods of rest as well as severe stertor and inspiratory dyspnoea. Echocardiography revealed degenerative mitral valve disease in stage B1 ACVIM (Keene et al., 2019) without any evidence of pulmonary hypertension. Respiratory tract endoscopic examination revealed a significantly enlarged soft palate, laryngeal saccule eversion and severe laryngeal collapse. During syncopal episodes, Holter examination revealed progressive bradycardia with long periods of sinus and ventricular arrest, followed by paroxysmal runs of atrial fibrillation, suggestive of reflex syncope. This case describes a dog with reflex syncope occurring in an atypical situation of rest with spontaneous improvement of syncope frequency until its complete resolution 6 months after presentation.

Introduction Congenital nasal pyriform aperture stenosis (CNPAS) is a rare congenital condition of structural nasal obstruction. Respiratory distress, stertor, and poor feeding are often presenting features. Case Presentation We report a case of a newborn diagnosed with CNPAS at 3 weeks of life. The diagnosis was missed on a nasoendoscopy at day 3 of life but was realised following a facial CT when the infant presented with ongoing symptoms of upper airway obstruction. Nasal dilation was performed successfully. Conclusion CNPAS should be considered in any neonate with upper airway obstruction. A normal nasoendoscopy does not exclude the diagnosis.

A six-year-old, male, castrated European shorthair cat was presented due to a lifelong history of sneezing, nasal discharge, open-mouth breathing, stertor and vestibular problems. Clinical examination showed absence of airflow through the nostrils. Computed tomography of the head revealed an infiltrative soft tissue attenuating mass in the left nasal cavity, nasopharynx and the left frontal sinus. All of these locations could be successfully accessed through ventral rhinotomy and the mass was completely removed. Histological examination identified it as an inflammatory polyp. All respiratory and neurological symptoms disappeared, and two-and-a-half years after surgery, the cat was still without complaints.

INTRODUCTION Pediatric sleep disordered breathing (SDB) is characterized by long periods of partial upper airway obstruction (UAO) with low apnea-hypopnea indices (AHI). By measuring snoring and stertor, Sonomat studies allow quantification of these periods of partial UAO. AIM To determine whether transcutaneous CO2 (TcCO2 ) levels correlate with increasing levels of partial UAO and to examine patterns of ΔTcCo2 in the transitions from (a) wakefulness to sleep and (b) non-rapid eye movement (NREM) to rapid eye movement (REM) sleep. METHODS This was a retrospective review of sleep studies in seven asymptomatic controls aged 7 to 12 years and 62 symptomatic children with suspected SDB and no comorbidities, aged 2 to 13 years. Both groups underwent overnight polysomnography, including continuous TcCO2 , at one of two pediatric hospitals in Sydney. Changes in carbon dioxide levels between wake to NREM (sleep onset) and NREM to REM sleep were evaluated using an all-night TcCO2 trace time-linked to a hypnogram. Paired Sonomat recordings were used to quantify periods of UAO in the symptomatic group. RESULTS The ΔTcCO2 at sleep onset was greater in SDB children than controls and ΔTcCO2 with sleep onset correlated with the duration of partial obstruction (r = .60; P

ObjectiveTo describe the utility of sleep nasendoscopy in determining the level of upper airway obstruction compared to microlaryngotracheobronchoscopy.MethodsA retrospective observational study was conducted at a tertiary level paediatric hospital. Patients clinically diagnosed with upper airway obstruction warranting surgical intervention (i.e. with obstructive sleep apnoea or laryngomalacia) were included. These patients underwent sleep nasendoscopy in the anaesthetic room; microlaryngotracheobronchoscopy was subsequently performed and findings were compared.ResultsTwenty-seven patients were included in the study. Sleep nasendoscopy was able to induce stridor or stertor, and to detect obstruction at the level of palate and pharynx, including tongue base collapse, that was not observed with microlaryngotracheobronchoscopy. Only 47 per cent of patients who had prolapse or indrawing of arytenoids on sleep nasendoscopy had similar findings on microlaryngotracheobronchoscopy. However, microlaryngotracheobronchoscopy was better in diagnosing shortened aryepiglottic folds.ConclusionThis study demonstrates the utility of sleep nasendoscopy in determining the level and severity of obstruction by mimicking physiological sleep dynamics of the upper airway.

Introduction: Respiratory distress frequently occurs in neonates and has a broad differential diagnosis. Although the majority of cases are due to lower respiratory pathology, anatomic defects of the upper respiratory tract must be considered. We present a case of neonatal respiratory distress caused by a congenital dacrocystocele. Case Description: A term female infant was born via vaginal delivery. Initial physical exam was normal. At approximately 6 hours of life, the infant developed retractions, nasal flaring, and high pitched inspiratory stertor appreciated best over the left nare. No external malformations were noted. The patient was transferred …

Purpose Polysomnography is not recommended for children at home and does not adequately capture partial upper airway obstruction (snoring and stertor), the dominant pathology in pediatric sleep-disordered breathing. New methods are required for assessment. Aims were to assess sleep disruption linked to partial upper airway obstruction and to evaluate unattended Sonomat use in a large group of children at home. Methods Children with suspected obstructive sleep apnea (OSA) had a single home-based Sonomat recording (n = 231). Quantification of breath sound recordings allowed identification of snoring, stertor, and apneas/hypopneas. Movement signals were used to measure quiescent (sleep) time and sleep disruption. Results Successful recordings occurred in 213 (92%) and 113 (53%) had no OSA whereas only 11 (5%) had no partial obstruction. Snore/stertor occurred more frequently (15.3 [5.4, 30.1] events/h) and for a longer total duration (69.9 min [15.7, 140.9]) than obstructive/mixed apneas and hypopneas (0.8 [0.0, 4.7] events/h, 1.2 min [0.0, 8.5]); both p

Background/Aim: The success of surgical treatment for pediatric sleep-disordered breathing is typically assessed using the mixed and obstructive apnea/hypopnea index (MOAHI). Although an important metric, previous work has shown that snoring/stertor are also associated with sleep disruption. Our aim was to assess the efficacy of surgery using the Sonomat, a non-contact sleep assessment system, that accurately records complete and partial upper airway obstruction. Methods: Forty children (l18yrs) had a Sonomat study, in their own beds, before and after surgery. As a MOAHI ≥1 event/hr is considered abnormal the same threshold was applied to snore/stertor runs. Median (interquartile range) values are reported. Results: Respiratory event induced movements decreased from 12.0 (8.7, 19.0) to 0.5 (0.1, 3.2)/hr (pl0.01), with no significant change in spontaneous movements 12.8 (9.8, 17.9) to 16.5 (13.7, 26.1)/hr (p=0.07). The MOAHI decreased from 4.5 (1.9, 8.6) to 0.0 (0.0, 0.4)/hr (pl0.01). Snoring/stertor runs decreased from 32.8 (23.4, 44.4) to 3.0 (0.2, 14.6)/hr, (pl0.01). Thirty-four children had a MOAHI l1/hr following surgery, however, 20 had snore/stertor runs ≥1/hr and 11 for ≥5/hr. Only 14 (35%) children had a post-surgery MOAHI l1/hr combined with snoring/stertor l1 run/hr. Conclusions: Although surgery is effective in improving breathing, success rates are over-estimated using the MOAHI. Our results indicate that snoring/stertor is still present at levels that may disrupt sleep despite a normalization of the MOAHI. As sleep disruption is linked to behavioral outcomes this is an important finding. Sleep investigations should include measurement of snoring and stertor.

In humans, classification of abnormal breathing patterns (ABP) and recognition of ancillary respiratory signs are difficult, as reflected by poor-to-moderate interclinician agreement. The aims of this study were to assess interclinician agreement for respiratory sign recognition in dogs and cats and evaluate the influence of clinical experience on agreement. Dogs and cats with ABP were recruited from three hospitals. Included animals were evaluated by three clinicians at each hospital before therapeutic intervention. Consensual definitions for each respiratory clinical sign were provided to all clinicians. Interclinician agreement was measured via Fleiss' kappa and intraclass correlation coefficient statistics. Influence of clinical experience on interobserver agreement was studied via mixed-effects logistic regression. One-hundred and fifteen dogs and 49 cats with ABP were recruited. Out of 12 clinical signs evaluated, only stertor (kappa, 0.80), stridor (kappa, 0.64), attenuation of heart/lung sounds (kappa, 0.60), and goose honking (kappa, 0.84) in dogs, and stertor (kappa, 0.65) and open-mouth breathing (kappa, 0.75) in cats, were considered sufficiently reliable among clinicians. Agreement on respiratory rate estimation was good in both species (intraclass correlation coefficient, 0.75). The greater the difference in clinical experience between two clinicians, the lower the odds of agreement between the two clinicians' respiratory physical examination findings. Interclinician agreement was demonstrated to be poor for recognition of most respiratory clinical signs in dogs and cats. Teaching and clinical experience acquisition should be encouraged to improve respiratory clinical sign recognition.

1. Daniela Titchiner, MD* 2. Priya Dukes, MD* 3. Rebecca Speier, MD* 4. Sharla Rent, MD* 1. *Duke University Hospital, Durham, NC 1. Address correspondence to Daniela Titchiner, MD, Department of Neonatology, Duke University Hospital, 2301 Erwin Rd, Durham, NC 27710. E-mail: daniela.titchiner{at}duke.edu A 3.8-kg male infant is born at 40 weeks’ gestation to a 30-year-old primigravida woman via normal spontaneous vaginal delivery. The pregnancy is uncomplicated, with appropriate prenatal care. Delivery is uneventful; the patient receives routine delivery care with Apgar scores of 7 at 1 minute and 9 at 5 minutes. The infant is transferred to newborn nursery with no complications. At 19 postnatal hours, he develops persistent tachypnea and stertor. The patient’s nares are suctioned bilaterally, followed by frank epistaxis and 2 episodes of bloody emesis. As a result, he is admitted to the NICU due to concern for respiratory distress and evaluation of bloody emesis. Initial examination in the NICU reveals an appropriate for gestational age term infant with mild tachypnea with RR 80, no increased work of breathing, saturating > 97% on room air. Chest radiograph demonstrates no abnormalities. The results of a complete blood cell count and coagulation studies are within normal limits. The examining NICU physician notes a soft-tissue mass in the left nasal meatus, without facial asymmetry or visible oropharynx abnormality noted. Pediatric otolaryngology (ENT) department is consulted and via flexible fiberoptic laryngoscopy visualizes a “soft, pink, mass in the …

PLEASE NOTE THAT A MORE RECENT EDITION OF THIS TITLE IS AVAILABLE IN THE LIBRARYNasal disease is common in the dog and cat, often presenting as a nasal discharge, with or without sneezing, stertor or stridor. Epistaxis may or may not be a feature, and can be present alone. Access to the rhinarium is difficult, since it is entirely encased in bone apart from at either end, and contains numerous turbinate scrolls forming many blind-ending channels in which foreign bodies or pathological changes can be hidden. There are only a limited number of direct physical approaches to the nasal cavity: dorsal rhinotomy; ventral rhinotomy; and rhinoscopy. Rhinoscopy is minimally invasive, providing reduced morbidity over other surgical options, and affords the best option for visualizing lesions and taking biopsy samples for diagnostic work, either for initial diagnosis or to confirm a suspected diagnosis. This chapter discusses Anatomical considerations; Indications; Preoperative diagnostic work-up; Intraoperative diagnostic work-up (under general anaesthesia); Instrumentation; Premedication and anaesthesia; Procedure; Caudal (posterior, retropharyngeal) rhinoscopy; Anterior (rostral) rhinoscopy; Frontal sinus exploration; Pathological conditions; Fungal rhinitis topical therapy; Postoperative care; and Complications.

We report a case of neonatal respiratory distress caused by an epignathus. This rare tumour, arising from the basisphenoid and protruding from the mouth, is associated with high perinatal mortality. We highlight unique clinico-radiological findings and multidisciplinary approach for a successful outcome. We review oropharyngeal teratomas reported in the literature with current management approaches.

Background Respiratory distress is a frequent occurrence in neonates, typically caused by a variety of pulmonary conditions. Accurate diagnosis of the cause is vital to appropriately treat neonates and prevent long-term complications. Neck masses rarely cause respiratory distress in this setting but should be considered when clinical signs indicate. Methods The authors present the patient with a neonate born at term who developed stertor, respiratory distress requiring intubation, and repeated failure to extubate. Results Physical examination showed right-sided lower and midface enlargement with a firm mass mostly over the parotid and right neck. Both computerized and magnetic resonance tomography demonstrated a right-sided neck mass. Surgical exploration revealed extensive tumor burden emanating from the great auricular, hypoglossal, and other nerves of the neck, including invasion of the carotid sheath encasing the artery. Excisional biopsy showed plexiform neurofibroma, and pathognomonic for neurofibromatosis type 1. The decision was made to pursue medical management, as complete excision would have resulted in increased morbidity due to the involvement of multiple cranial nerves. The patient underwent microlaryngoscopy, bronchoscopy, and tracheostomy and was started on Trametinib chemotherapy. Conclusion Neonatal airway obstruction can rarely be caused by unanticipated mass lesion, such as plexiform neurofibroma. A high index of suspicion must be maintained for early onset mass lesions causing respiratory obstruction to inhibit early disease progression and avoid potentially fatal sequelae.

A seven-year-old domestic longhair cat was referred with a history of recurrent stertor following conservative treatment. Nasopharyngoscopy showed a stenosis with an opening of 2 mm, which was dilated with cotton buds of increasing size. Histopathology of the stenosed tissues revealed chronic active inflammation. Dilatation relieved the clinical signs for four years before recurrence. The same procedure was repeated after the stenosis recurred, but the improvement lasted for only two weeks. At that point, a ‘balloon dilatation’ was performed using a Foley catheter. At the time of writing of this paper, the cat is still clinically normal (six months postprocedure).

An 8-year-old spayed female 32 kg Labrador retriever was presented for further investigation into the underlying cause of dyspnea, stertor, and sleep apnea present for three months and worsening over 30 days. There were significant reduction in airflow through the nares and loud inspiratory stridor. Thoracic and cervical radiographs made were normal. A skull CT and retrograde rhinoscopy showed a mass occluding the majority of the nasopharynx above the caudal third of the hard palate. The main differential diagnoses included a neoplastic mass vs. inflammatory mass vs. cyst vs. mucous obstruction. There was no destruction of nasal turbinates, making a benign etiology more likely. Biopsy of the mass showed an inflammatory process. En bloc excision of the mass was performed via ventral rhinotomy without complication. Histopathology of the excised mass revealed it to be a mucosal vascular hamartoma. The dog recovered uneventfully and had no further respiratory issues, short or long term. Although vascular hamartomas are a rare finding in veterinary medicine, they can be found in a wide variety of species and anatomic locations. They should be considered when naming differentials for benign mass lesions throughout the body, including the nasopharynx. Although they are benign masses in nature, they can be clinically significant and should be addressed. Prognosis after removal in this location is excellent.

Case summary An indoor-only 6-year-old spayed female domestic cat was evaluated for a history of stertorous respiration. Skull radiographs revealed increased soft tissue density within the caudal aspect of the left nasal cavity. CT and rhinoscopy revealed a mass lesion in the choana, plus a smaller lesion, nearly completely occluding flow through the nasal passages. Rhinoscopy was used to collect a biopsy specimen from a fleshy, tan–yellow mass visualized in the caudal nasopharynx. Histopathology was diagnostic for Cryptococcus species infection and systemic antifungal therapy with fluconazole was initiated. Following a series of discordant results, serum samples were submitted to a veterinary diagnostic laboratory that utilized a cryptococcal antigen latex agglutination system with pretreatment of serum with pronase. Twenty-three months after the initial diagnosis, the cat’s serum cryptococcal antigen titer declined to 1:5 and the cat has responded well to continuing treatment. Relevance and novel information This case illustrates challenges associated with discordant test results for cryptococcal antigen among laboratories. Discordancies may be due to differences in assay design, or the underlying disease state itself, or whether serum is pre-treated with pronase; with some tests relying on the training and experience of the operator if the cryptococcal antigen detection test requires a subjective interpretation. It also resolves some confusion in the literature related to the assay types available and terminology used to describe them, and emphasizes the importance of considering cryptococcosis as an important differential for cats with upper respiratory signs, without nasal discharge, even if the cat is kept exclusively indoors.

BackgroundMycotic rhinitis is a rare disease in horses, with few cases reported worldwide and none reported in Australia. Fungal infection of the upper respiratory tract can occur in all species, but its prevalence in horses is considerably lower than in canines or humans. The disease is linked to a variety of pathogens and the clinical signs are associated with subsequent upper respiratory tract damage.Case reportA 6-year-old Quarter Horse gelding in Queensland, Australia, was presented with chronic nasal discharge and dyspnoea following previous unsuccessful medical treatment of 9months' duration. Culture yielded a mixed growth of Cryptococcus and Rhodotorula, as well as secondary bacterial species. The horse was anaesthetised and positioned in sternal recumbency. The nasal passages and sinuses were bathed with fluconazole and dimethylsulfoxide for 1h on two separate occasions 4weeks apart. Systemic antimicrobials and corticosteroids were also administered for brief courses. Endoscopic examination 4months after treatment demonstrated clinical resolution of the rhinitis with residual scar tissue. Owners reported resolution of clinical signs and following the treatment the gelding was able to perform athletically.Clinical relevanceMycotic rhinitis is an unusual disease that can be difficult to treat successfully. This report describes a technique for topical sinonasal bathing under general anaesthetic that was well tolerated, easy to perform and resulted in a successful clinical outcome.

The diagnostic values of respiratory signs have been under-investigated in pets. The study aim was to explore commonly assumed associations between respiratory signs and disease localization in pets with abnormal breathing patterns (ABP). Dogs and cats with ABP presenting to three hospitals were included if investigations permitted disease localization. Hypothesized associations between respiratory signs and disease location were evaluated via mixed-effects logistic regression. Sensitivity, specificity, and positive diagnostic likelihood ratio were calculated. One-hundred and fifteen dogs and 49 cats with ABP were recruited. Confirmed associations included: inspiratory effort with extra-thoracic airway disease (odds ratio [OR], 9.1; 95% confidence interval [95% CI] 3.0-27.2); expiratory effort with intra-thoracic airway disease (OR, 6.5; 95% CI, 2.3-18.1); paradoxical breathing and attenuation of heart/lung sounds with pleural space disease (paradoxical breathing: OR, 4.5; 95% CI 1.7-12.1; sound attenuation: OR, 11.5; 95% CI 4.0-33.3); decreased nasal airflow and stertor with nasal/pharyngeal disease (nasal airflow: OR, 26.2; 95% CI 8.1-84.8; stertor: OR, 155.2; 95% CI 24.9-968.8); stridor with laryngeal or tracheal disease (laryngeal disease: OR, 39.9; 95% CI 7.6-209.0; tracheal disease: OR, 32.4; 95% CI 4.2-248.0); tracheal sensitivity with bronchial disease (OR, 3.8; 95% CI 1.5-9.6); crackles with pulmonary or bronchial disease (pulmonary disease: OR, 5.4; 95% CI 2.1-13.8; bronchial disease: OR, 3.9; 95% CI 1.6-9.8); and goose honking with tracheal disease (all dogs with goose honking had tracheal involvement). Select respiratory signs provide guidance to localize and prioritize causes of the underlying respiratory disease in pets, allowing targeted interventions in animals with ABP.

Case report A 6-week-old Thoroughbred filly was presented for evaluation of an expansile mass overlying the right nasal passage and causing respiratory stertor. On skull radiographs, there was a loculated, soft tissue-opaque mass identified dorsal to the right upper premolars and effacing the right nasal cavity. Computed tomography (CT) revealed a locally extensive mass with relatively benign characteristics located centrally on the tooth root apices of the deciduous second premolar (506). The mass extended axially into the right nasal cavity, occluding the meatuses and causing displacement of the nasal septum to the left. Clinical outcome & significance Surgical excision was not deemed feasible with an athletic future in mind and the owners elected to euthanase the filly. Histopathologically, the mass was consistent with unicystic ameloblastoma and was lined intermittently with palisading, columnar basal cells (ameloblast-like cells) overlying a zone containing stellate cells in loose stroma. To the authors’ knowledge this is the first report of a CT scan of an equine ameloblastoma. Although histopathology was essential for definitive diagnosis, CT clearly defined the origin of the mass and identified its locally extensive, cystic nature, which enabled informed decisions to be made.

To illustrate the clinical and radiological presentation of a rare etiology of nasal obstruction in neonates, midnasal stenosis (MNS), including a comparison of nasal dimensions with those of normal infants.We retrospectively reviewed medical charts and computerized tomography (CT) imaging of neonates with nasal obstruction diagnosed as stenosis in the midnasal area in a tertiary pediatric medical center. MNS was defined clinically by inability to visualize the middle turbinate with an endoscope despite the absence of stenosis of the anterior aperture or any gross septal deviation. CT measurements of the midnasal width were taken by an experienced neuroradiologist. We compared widths between the bony inferior turbinate to the bony septum in the narrowest area of symptomatic patients, to widths in a control group of asymptomatic children.Nine neonates from birth to three months old presenting with nasal obstruction, severe stertor, and blocked nasal passage at the midnasal level in endoscopic examination, were diagnosed with MNS. 6/9 had CT scans. Four had isolated unilateral stenosis, two unilateral MNS and contralateral choanal atresia, and three bilateral MNS. All patients were managed conservatively, initially with nasal saline irrigation and local steroids and topical antibiotics; Median time to resolution of symptoms was 14 days. When comparing the dimensions at the midnasal narrowest area of the stenotic group with a control group of 139 healthy children, the median bony width was 1.7 mm vs. 3.2 mm, respectively (p 0.00001). Average dimensions according to age groups until the age of 12 months are given.In neonates with nasal obstruction, when choanal atresia and pyriform aperture stenosis are excluded, stenosis of the midnasal area should be considered. Most of these neonates can be managed conservatively.4.

The objective of the present study was to determine the association between respiratory stertor and focal and bilateral seizure types.We characterized ictal and postictal behaviors during symmetric bilateral tonic-clonic (TC) and asymmetric TC seizures in the Johns Hopkins University (JHU) epilepsy monitoring unit, comparing these to focal unaware seizures. We measured the presence and duration of postictal stertorous respirations, postictal generalized electroencephalographic suppression (PGES), immobility/motor dysfunction, and encephalopathy and determined their associations and relationship to seizure types.In initial seizures recorded in 80 consecutive patients, bilateral symmetric TC seizures (N = 35) were strongly associated with PGES (97%, p 0.001) and postictal stertorous respirations (89%, p 0.001). Only 10% of the 20 patients with asymmetric TC seizures had brief PGES; focal unaware seizures (N = 25) were not associated with PGES or stertorous breathing. Some patients (24%) with asymmetric or bilateral symmetric TC seizures had severe postictal encephalopathy with stertor that was separate or extended beyond periods of PGES.Bilateral symmetric TC seizures, but not focal unaware seizures, have postictal stertor during PGES. Severe postictal encephalopathy, however, is also associated with motor dysfunction and stertor. Stertor appears to be a compensatory postictal respiratory pattern for ictal/postictal hypoxemia and occurs with PGES or postictal encephalopathy.

Twelve Texel sheep were found to have diaphragmatic lesions, with or without thoracic haemorrhage, at postmortem examination over a period of two-and-a-half years. Presenting clinical signs ranged from general malaise or mild respiratory stertor, to severe acute respiratory distress or sudden death. Gross postmortem findings included focal areas of diaphragmatic haemorrhage, diaphragmatic musculature necrosis or diaphragmatic rupture with herniation of abdominal viscera into the thoracic cavity. In some cases, acute severe fatal haemorrhage from either thoracic vessels or the diaphragmatic lesions was observed. Histopathology confirmed an acute event leading to the sudden death of affected animals, but also suggested a pre-existing chronic degenerative lesion of unknown aetiology affecting the diaphragmatic muscle. This case report suggests diaphragmatic lesions, with or without fatal thoracic haemorrhage, as a differential for respiratory distress or sudden death in young Texel sheep.

We share our experience on the implementation of a multidisciplinary aerodigestive program comprising an aerodigestive team (ADT) so as to evaluate its feasibility. We performed a retrospective chart review of the patients discussed at the monthly ADT meetings and analyzed the data. A total of 98 children were referred to the ADT during the study period. The number of cases increased steadily from 3.5 cases per month in 2019 to 8.5 cases per month in 2020. The median age of patients was 34.5 months, and 55% were male. Among the chronic comorbidities, neurologic disease was the most common (85%), followed by respiratory (36%) and cardiac (13%) disorders. The common reasons for consultation were suspected aspiration (56%), respiratory difficulty (44%), drooling/stertor (30%), regurgitation/vomiting (18%), and feeding/swallowing difficulty (17%). Following discussions, 58 patients received active interventions, including fundoplication, gastrostomy, laryngomicrosurgery, tracheostomy, and primary dilatation of the airway. According to the questionnaire of the caregiver, the majority agreed that the main symptoms and quality of life of patients had improved (88%), reducing the burden on caregivers (77%). Aerodigestive programs may provide comprehensive and multidisciplinary management for children with complex airway and digestive tract disorders.

Unrelieved upper airway obstruction from highly prevalent adenotonsillar hypertrophy (ATH) has the potential of producing structural remodelling of the pulmonary vascular bed with resultant pulmonary hypertension (PH) and cor pulmonale. This cross-sectional study aimed to determine the local prevalence of PH and examine its clinical and radiological pointers among children with ATH. The airway obstruction was evaluated clinically by grading the nocturnal and daytime symptoms of ATH. A Brodsky scale and adenoid-nasopharynx ratio (AN ratio) were used to categorize tonsil and adenoid size, respectively. Mean pulmonary artery pressure (mPAP), was measured noninvasively for each child using Doppler echocardiography and PH was defined by mPAP ≥25 mmHg. Comparison of symptom scores, tonsil and adenoid size and demographic factors was made between children with mPAP ≥25 mmHg and those mPAP25 mmHg using univariate and multivariate analysis. There was 22.8 % (18/79) prevalence of PH among the 26 children with only adenoid hypertrophy and 53 with ATH. Significant risk factors identified by logistic regression analysis associated with PH were daytime mouth breathing, daytime stertor, and AN ratio0.75 (P = 0.002, 0.018, and 0.04, respectively), with more than sixfold and fourfold increase risk for daytime mouth breathing and daytime stertor, respectively. Obstructive breathing during sleep was significant only on univariate analysis. Prolonged symptom duration ≥24 months, large tonsils (grades 3 and 4), snoring and mouth breathing during sleep were not significant. This study demonstrated that pulmonary hypertension remains prevalent in children with ATH. Daytime mouth breathing and stertor as well as AN ratio0.75 are the prime predictors of pulmonary hypertension, with an AN ratio cut-off point of 0.73 on ROC analysis.

Objective To present the outcomes of neonatal nasolacrimal duct cysts treated through endoscopic intranasal marsupialization under topical anaesthesia. Methods A retrospective study of 19 infants diagnosed with congenital nasolacrimal duct cyst, with or without dacryocystocele, diagnosed and treated between March 2015 through March 2020. Data were extracted for descriptive purposes and included: birth weight, main presenting symptom, stertor or dyspnoea, unilateral or bilateral occurrence. Follow-up one month after intervention included recurrence of symptoms, physical examination and fibreoptic naso-endoscopy. Results Nineteen infants with intranasal cyst were presented to our department at the age of 1 day. Four-teen infants had unilateral and 5 infants had bilateral intranasal cysts. There were 8 boys and 11 girls. Mean gestational age at birth was 39 weeks, mean birth weight was 3351 g. 42.1% of infants presented with dacryocystocele, 31.5% with stertor, and 26.3% with dyspnoea. 80% of infants with bilateral cysts presented with dyspnoea. Follow up ranged from 6 to 48 months, no recurrence of symptoms was reported. Conclusion Intranasal endoscopic marsupialization under topical anaesthesia is a successful, safe, low cost procedure for treating neonatal nasolacrimal duct cysts while avoiding general anaesthesia for infants.

Case summary A 12-year-old male neutered domestic shorthair cat underwent rhinoscopy due to inspiratory dyspnoea and stertor. Rhinoscopy showed signs of chronic rhinitis and a multinodular nasopharyngeal mucosa. A marked infiltrate of macrophages that contained intracellular parasitic forms morphologically compatible with Leishmania amastigotes were observed on histopathological examination of nasal and nasopharyngeal biopsies. PCR from nasal tissue was positive for Leishmania infantum DNA, confirming the diagnosis of granulomatous rhinitis secondary to this parasite. Two eyelid nodules were identified 2 weeks later. Fine-needle aspiration revealed Leishmania amastigotes within macrophages and in the background. Allopurinol therapy was started, but 5 days later the cat developed dermatological signs compatible with a cutaneous adverse drug reaction. The drug was discontinued and meglumine antimoniate prescribed. Twenty-five days later, the cat presented with acute kidney injury and meglumine antimoniate was discontinued. Despite clinical improvement after fluid therapy, mild azotaemia persisted. The cat was subsequently treated with nucleotides and active hexose correlated compounds (N-AHCC). Four months later upper respiratory signs were exacerbated. A relapse of granulomatous rhinitis was suspected and miltefosine therapy started. Chronic kidney disease (CKD) worsened during miltefosine treatment, having improved under fluid therapy. Since then, the cat has been treated with N-AHCC and renal diet and at the time of writing shows stable CKD with no recurrence of respiratory signs. Relevance and novel information This case describes Leishmania infantum as a cause of granulomatous rhinitis in a cat without cutaneous lesions, reporting the alternative use of N-AHCC and miltefosine when allopurinol seemed to have induced a cutaneous rash and there was acute kidney injury (AKI) after meglumine antimoniate therapy.

Objective To describe the use of extended palatoplasty as treatment of caudal nasopharyngeal stenosis in cats. Materials and methods CT was used to confirm the diagnosis in cats with clinical signs consistent with nasopharyngeal stenosis. Extended palatoplasty rostral to the tonsils using monopolar electrocautery allowed simultaneous removal of the caudal soft palate together with the stenotic area. Cats were re-evaluated 2 weeks postoperatively. Telephone interview was used to obtain long-term follow-up. Results Six domestic shorthair cats were diagnosed with nasopharyngeal stenosis, with clinical signs of snoring (n=4), stertor (n=4), nasal discharge (n=3) and sneezing (n=1). CT scan identified a soft-tissue stricture at the level of the caudal nasopharynx in all cats. Other abnormalities included bilateral rhinitis (n=3), retropharyngeal adenomegaly (n=2), unilateral sinusitis (n=1) and bilateral otitis externa with unilateral otitis media (n=1). Excision of the caudal soft palate and the entire stenotic soft-tissue membrane was successful in all six cats. No pre-, intra- or postoperative complications were observed. Short-term outcome revealed clinical improvement in all cases. Long-term outcome revealed no recurrence of clinical signs in four cats. In one cat, occasional sneezing was reported. One cat died 1 month postoperatively for reasons unrelated to the respiratory condition. Clinical significance Extended palatoplasty was an effective technique to treat caudal nasopharyngeal stenosis and provide improvement of clinical signs without postoperative complications in all cases.

Many neoplasms have been reported in goats; however, neoplasia of the rumen is rarely reported. A 9-y-old castrated male pygmy goat was presented with a history of respiratory stertor, fever, and anorexia. A respiratory diagnostic work-up including skull and thorax radiographs and endoscopy revealed minor enlargement of the arytenoids but no other abnormal findings. After a month of little improvement on symptomatic treatment and worsening general health, the goat was euthanized. On autopsy, the forestomachs, liver, spleen, diaphragm, and the ventral and lateral aspects of the cranial third of the walls of the peritoneal cavity were adhered to one another by fibrinous and fibrous adhesions. Numerous firm, white, up to 2 cm diameter nodules were found throughout the liver. A large sessile mass extended from the rumen wall into the lumen. The rumen mass was a gastrointestinal stromal tumor with metastasis to the liver.

Evaluation of the infant with noisy breathing can be intimidating as it suggests some degree of airway obstruction. Knowledge of airway anatomy and the common causes of noisy breathing in this patient population is critical in making the diagnosis and determining the next step in clinical management. A focused history with emphasis on birth, intubation, and feeding history as well as a complete head and neck examination often yield the diagnosis. The clinician must be able to differentiate stridor from stertor as well as determine whether the airway noise is inspiratory, expiratory, or biphasic. The phase of respiration in which the noise is best heard is an important clue to the level of airway obstruction. Evaluation with awake flexible fiberoptic laryngoscopy (FFL) and/or sedated airway endoscopy is often required for diagnosis and intervention. Differentiating nasal and pharyngeal sources of obstruction from laryngeal anomalies is important for determining urgency of management. Laryngomalacia, congenital or acquired subglottic stenosis, and airway hemangioma are the most common laryngeal sources of noisy breathing in infants. Respiratory papillomatosis and airway foreign body should also be considered but are less common causes. Proper identification, management, and understanding of the current trends in treating these conditions will ensure the best possible patient outcomes.

Importance Paradoxical vocal fold motion (PVFM) is a disorder often misdiagnosed in children presenting with shortness of breath and stridor. In infants, little is known about the clinical course and best approach for treatment of PVFM. This retrospective study assesses the approach to treatment and outcomes for infants with PVFM. Objective To investigate the clinical course of paradoxical vocal fold motion (PVFM) in infants. Design Retrospective review. Setting Tertiary academic medical center. Participants Patients less than 2 years of age diagnosed with PVFM were identified and included in the study. Main outcomes and measures History, physical exam findings, and clinical course of treatment for patients less than 2 years old with PVFM were reviewed. Findings including those on flexible fiberoptic laryngoscopy (FFL) and subjective assessment by parents and clinicians were compiled for review. Results Seven infants were diagnosed with PVFM. All patients were full term at birth, and average age at diagnosis was 7 months. All patients initially presented with inspiratory stridor, and two patients had stertor. Two of seven patients also had a history of reactive airway disease and one with laryngomalacia. Five had a history of reflux. Two of seven patients had weight percentiles at diagnosis lower than the 25th percentile, while the remainder were between 37th and 75th percentiles. Initial voice evaluation revealed stridor in all patients, as well as finding of PVFM on FFL. All patients were started on anti-reflux medication. Average time to resolution of PVFM was 5.9 months after treatment. Conclusions PVFM can be challenging to diagnose in the infant population. PVFM resolves uneventfully with reflux treatment, however, it is unknown whether reflux treatment is essential or if PVFM would spontaneously resolve. The rarity of infantile PVFM mandates formal evaluation and monitoring by a pediatric otolaryngologist.

An 8-year-old Labrador Retriever was presented for inspiratory efforts with stertor. A rhinoscopy and a magnetic resonance imaging scan were performed and revealed a naso-pharyngeal mass. The mass was identified in the nasopharynx without meningeal extension. This mass was both T1- and T2-hyperintense, compared to normal brain parenchyma without significant postcontrast enhancement. The mass was surgically removed and the histologic diagnosis was a mesenchymal tumor. Immunohistochemistry with antibodies was conducted and consistent with an extracranial meningioma. To the authors' knowledge, this is the first case report documenting a primary extracranial nasopharyngeal meningioma in a dog.

Five dogs were presented with clinical signs compatible with upper airway obstruction, including stridor, stertor, coughing, gagging, and varying degrees of respiratory distress. All dogs had radiographic findings of soft tissue opacity in the area of the pharynx, larynx, or trachea, and several had narrowing of the tracheal lumen. Coagulation abnormalities (prolonged prothrombin time, activated partial thromboplastin time) were present in the four dogs that underwent testing. Four of five dogs were treated for the coagulopathy, presumably due to anticoagulant rodenticide toxicosis, and survived to discharge.Upper airway obstruction is an unusual presentation for anticoagulant rodenticide toxicosis in dogs. Raising the index of suspicion for this treatable condition may help clinicians to identify this sooner.

Study objectives To validate the Sonomat against polysomnography (PSG) metrics in children and to objectively measure snoring and stertor to produce a quantitative indicator of partial upper airway obstruction that accurately reflects the pathology of pediatric sleep-disordered breathing (SDB). Methods Simultaneous PSG and Sonomat recordings were performed in 76 children (46 male, age 5.8 ± 2.8, BMI = 18.5 ± 3.8 kg/m2). Sleep time, individual respiratory events and the apnea/hypopnea index (AHI) were compared. Obstructed breathing sounds were measured from the unobtrusive non-contact experimental device. Results There was no significant difference in total sleep time (TST), respiratory events or AHI values, the latter over-estimated by 0.3 events hr-1 by the Sonomat. Poor signal quality was minimal and gender, BMI, and body position did not adversely influence event detection. Obstructive and central events were classified correctly. The number of runs and duration of snoring (13 399 events, 20% TST) and stertor (5748 events, 24% TST) were an order of magnitude greater than respiratory events (1367 events, 1% TST). Many children defined as normal by PSG had just as many or more runs of snoring and stertor as those with mild, moderate and severe obstructive sleep apnea (OSA). Conclusions The Sonomat accurately diagnoses SDB in children using current metrics. In addition, it permits quantification of partial airway obstruction that can be used to better describe pediatric SDB. Its non-contact design makes it ideal for use in children.

Acute airway obstruction is a common ENT emergency with a wide range of aetiologies. The most common causes are infection, malignancy and foreign bodies, but more unusual causes should be considered.1 A 77-year old gentleman presented to the emergency department with worsening difficulty in breathing for 3 months since undergoing spinal surgery for multilevel cervical myelopathy. He of stertor, cough, dysphagia and intermittent apnoea. He was otherwise systemically well with no clinical signs of sepsis. Flexible nasendoscopy revealed a large posterior pharyngeal wall mass obscuring the …