The brachycephalic dog’s respiratory passage begins with very small, often slit-like, nasal openings for breathing. This leads to a great deal of open-mouth breathing and panting as the nasal breathing route is limited by its small opening. Stenotic nares can be surgically corrected after five months of age.

The tongue of the brachycephalic dog can be particularly thick and large which contributes to the overall obstruction.

It is difficult to fit the soft tissues of the canine mouth and throat into the brachycephalic’s short face. As a result, the soft palate which separates the nasal passage from the oral cavity, flaps loosely down into the throat creating snorting sounds. Virtually all brachycephalics suffer from this. Excess barking or panting may lead to swelling in the throat that can in turn, lead to severe respiratory distress. Again, the soft palate can be surgically trimmed.

The normal larynx has two small pockets called ventricles or saccules. When a dog has increased effort to breathe, over time these little pockets will actually turn inside out and can obstruct the throat. This condition can be corrected surgically however, in many cases it can be prevented by early surgical correction of the nares and/or elongated soft palate.

Brachycephalic obstructive airway syndrome can be progressive if it is not corrected at an early stage. Severely affected dogs can experience collapse of the larynx and require a permanent tracheotomy (a hole in the throat for breathing).

There appears to be several stomach and swallowing issues that are caused by the constant negative pressure of upper airway obstruction. The oesophagus (the tube that moves swallowed food from the throat to the stomach) experiences reflux of stomach contents. This reflux generates pain and inflammation. Compounding this problem is retention of food in the stomach for prolonged periods. Pooling of food in the stomach creates a sensation of nausea and increases the potential for vomiting and/or stomach acid reflux. Medications can be used to manage these issues (should they arise); however, surgical correction of the respiratory obstruction generally leads to great improvement of the gastrointestinal symptoms.

At Southern Animal Health our advanced surgeon Dr. Karin David’s is capable of correcting all these upper airway defects for your pet. Due to the progressive nature of BOAS, we recommend correction sooner rather than later. These surgical corrections can be done as early as 8-12 months of age under the same general anaesthetic as desexing.

All patients should be assessed at desexing and most will benefit from nares and soft palate resection at this time. When done early, laryngeal saccules rarely need to be removed.

If not done at desexing, surgery can still be performed in later years with good results, but the results are never as positive long term compared to early correction at desexing. So please consider and discuss these corrective surgeries with us before desexing. Early correction is most effective and cost efficient, leading to the patient having a vastly improved life due to easier breathing.

If any of the above procedures are done at the same time as desexing, the cost is far cheaper (and long term benefits far greater). Done as a separate surgery later in life, the base cost of soft palate resection is far higher with nares and laryngeal saccules (likely needing to be done after 2 years of age).

• Feed soft food only for the first 48 hours after surgery
• On rare occasions the ‘snoring’ and ‘snorting ‘ may seem worse for a day or two post op due to swelling at the back of the throat, but becomes vastly improved soon after.
• Medications: Your dog will need to take anti-inflammatories and antibiotics for 5-7 days post surgery.

Other than the extremely rare usual complications of all surgery, such as bleeding or infection, on rare occasions we may need to do a second resection at a later time.

Overall the surgery is very successful and the risk of complications is extremely low. Thus there is an excellent chance of improving your dog’s respiratory difficulties, exercise intolerance and overall quality of life. Early correction is the key to a better long term result.

Many pet owners having had BOAS surgery in Melbourne (often via specialist surgeons), with relatively poor results, have sought a second opinion from Karin, with re-assessments often finding the following:

• A palate has only been partially resected compared to what we remove at Southern Animal Health (SAH)
• Palates have rarely been thinned, being left with a thickness that takes up a significant proportion of the little room these dogs have in their pharynx.
• Laryngeal saccules either left (seen in the vast majority of patients) or only partially removed, needing to be revised.
• Tonsils incorrectly assessed as normal and left in that would benefit from being removed.
• Nares not deepened or widened as much as SAH would.

Our revision surgeries almost always result in vastly improved patients. Hence, we have learnt over the years that there is great variability and subjectivity from surgeon to surgeon with regards to the 5 aspects that can be corrected in BOAS. Dr Karin, through approximately 1,500 surgeries over the years, is one of Australia’s most experienced, but also most progressive surgeons, given the results from the revision surgeries we have performed.

Working in combination with Dr Marcus Hayes from the medical aspect, SAH has significantly refined not only the surgical correction of BOAS sufferers, but also their management from a medical and behavioural concern. This has helped us achieve a far greater safety record from surgery itself, as well as the best possible long-term improvement after airway correction.

Through two separate studies we have had the following results:

Study 1: 67 cases 3 months post boas showed 0% worse, 2% no change and 98% improved with the vast majority being significantly improved.

Study 2: 150 cases 12 months post-surgery showing 7% no change, 93% improved with the vast majority significantly improved.

Given almost 100% of non-airway corrected dogs show significant deterioration in exercise ability from year to year, the 12-month stats above are remarkable. The 7% no change dogs will likely have been the severely progressive ones had their airways not been improved.

One concern people have with BOAS surgery however, is the potential for post-surgical swelling and complications such as aspiration pneumonia, the need for a temporary tracheotomy tube or even death. The following highlights how we have virtually minimised these risks by modifying traditional methods.

One of Australia’s leading and world-renowned specialist centres for BOAS surgery have communicated their following overall complication rates, feeling they are on the lower end of the scale on a world basis:

• Approximately 17% need oxygen treatment for 36 hours
• Approximately 5% have major complications such as aspiration pneumonia and the need of a temporary tracheotomy tube to help them breathe.
• A range of 0.5 to just under 1% death rate

In comparison, SAH have recorded the following concerns through approximately 2,300 surgeries:

• No dogs needing oxygen treatment for 36 hours.
• 0% aspiration pneumonia (1 case developed these 5 days post-surgery despite being 100% in those initial 5 days, but quickly resolved)
• 0.8% tracheotomy tubes (of which about 1/3 were placed electively pre-extubation for very high-risk patients in late stage 2 laryngeal collapse)
• 0.1% death rate (only 2 dogs that delayed surgical correction for too long and were very high-risk cases. We have corrected 50-100 such high-risk cases with no concern)

Hence our advice is that through progression of both surgical techniques, and more modern medical and behavioural practices, we have resulted in an almost 10X reduction of severe complications or death than Australia’s leading specialist centres.

The following are the reasons for this:

1) A far more pro-active approach to maximising the room in the back of the pharynx via more length and thickness of palate removed, and removal of laryngeal saccules and tonsils in almost every case. In addition to this we also do a wider and deeper nares resection. All this extra room results in two advantages; far less chance of complications with post-surgical swelling, and far improved long term results.

2) A move away from traditional Nsaids to steroids as the best post-surgical anti-inflammatory. Nsaid’s do not reduce or prevent pharyngeal swelling to nearly the same extent as steroids. We urge all surgeons to understand the importance steroids play in minimising swelling and post-surgical reflux, which is very important to reduce the potential for aspiration pneumonia.

3) The use of metoclopramide preferentially to omeprazole for reflux control.

4) Allowing owner presence for any anxious dogs in recovery. This is another very important aspect of lowering complication rates. We urge specialists to understand the importance of this aspect of stress management to lessen post-surgical swelling. Many specialists still refuse owner presence when required. SAH surgeons will not schedule surgery unless you advise you are available if needed.

5) Same day discharge: Stress leads to swelling. Getting these dogs home once they are breathing well, (which is 2-5 hours for 99% of patients with above protocols), is key to higher success and recovery. We have followed many specialist cases that have resulted in aspiration pneumonia, temporary tracheotomy tube and even death, that were relatively fine immediately post-surgery, but started their downward spiral during the night of what we believe is the unnecessary 24 hour stay. We feel 24-hour stays greatly increase the risk of severe complications and death.

Upon discharge our highly experienced BOAS nurses give lengthy explanations to pet owners about what to look for should you need to consider going to your nearest emergency (a list is provided).

Through 2,300 surgeries which we have sent home the same day, only three people have been concerned enough to go to emergency (as 99% are showing improved and content signs since getting home). Two of these cases were fine and sent straight back home. One was kept 12 hours for observation with a tracheotomy tube placed (one of the 0.8% compared to 5% for Australia’s most renowned specialist centre for BOAS surgery).

Hence risks associated with BOAS surgery are virtually non-existent when modern surgical, medical and management protocols are followed, and patients are corrected early, before very advanced boas exists (8-14 months, breed dependent).

SAH have developed and refined these protocols over many years and urge all surgeons to open discussion to help as many of these dogs achieve the safest surgery and best long-term results possible.

Stage 3 laryngeal collapse occurs when airway concerns are severe and chronic enough to cause the larynx cartilages to collapse, no longer opening with each breath. In the past this has generally led to either euthanasia or the need for a permanent tracheostomy. A permanent tracheostomy is a surgically created hole halfway down the neck through which the dog breathes for the rest of its life. These are expensive, complicated, and difficult to manage the first 6 months. Many people choose euthanasia instead.

Dr Karin Davids was a pioneer in Australia of bilateral cuneiformectomy, a procedure where we remove the two collapsed cartilages. Karin has talked some of Melbourne’s best surgeons through this procedure once they saw our own success with it.

With very good success now being demonstrated with bilateral cuneiformectomy, brachycephalic owners now have excellent choices for those severe cases who were left too long for airway correction.