Holistic Care of Laryngeal Paralysis in Dogs

Laryngeal paralysis has been one of my harder to treat diagnoses in dogs but some recent ah-ha moments that originated from my own dog has given me hope for the conservative and effective management of more dogs with this condition. My thought patterns on how to treat it is a great showcase on what holistic medicine is - a deep understanding of the anatomy, science and all the tools available we can use including nutrition, functional anatomy with biomechanical treatments, rehabiliation exercises, acupuncture, nutrition, microbiome manipulation, herbal therapies, laser (and this list will grow). Strap in for this blog - it might be a bit complex! And not everything here has a study to back it up but if there happen to be other practitioners that see this I'd love to hear your thoughts on laryngeal paralysis and what you do.

Laryngeal paralysis is often referred to as geriatric onset laryngeal paralysis and polyneuropathy (GOLPP). Laryngeal paralysis is a condition where the nerve to open the muscles of the larynx doesn't work effectively. This leads to the symptoms of difficulty breathing, noisy breathing or 'stridor', reduced exercise tolerance, coughing - often when eating or drinking and the reduced ability to effectively pant which means dogs are at a high risk of heat stress. Owners of a GOLPP dog are often quite distressed by the effects of this condition on their dog.

The traditional treatment method has been surgery for this condition. In surgery one of the sides of the larynx are surgically and permanently opened in a 'tie back' procedure. This can be effective for some dogs but often comes at a stage in life when when we don't want to be putting old dogs through surgery. Additionally, dogs that have had a tie back surgery are at increased risk of aspiration pneumonia as they can't close their airways properly. Given these issues with surgery additional conservative treatment methods need to be considered for each individual, and also may be considered in dogs that also go on to have surgery for their general health.

Anatomy

To understand the pathology of the condition we first need to understand the anatomy. When I teach in anatomy pracs to vet students looking at the Vagus nerve is one of favourite things to discuss because it is so interesting! The vagus nerve starts in the brain as the 10th cranial nerve. The paired left and right vagus nerves exit the back of the skull then run down the front of the neck, through the thoracic inlet where the first ribs create an opening into the thorax, into the middle cervial ganglia in the cranial mediastinum (front of the chest). The nerve leaves the ganglia, heads past the heart to find the oesophagus and then splits into a dorsal and ventral branch. Each dorsal and ventral branch finds it's counterpart from the otherside and we have a common dorsal and ventral branch formed (rather than a left and right nerve). These nerves follow the the oesophagus through the diaphragm into the abdomen to innervate most of the digestive organs.

So what has this got to do with the larynx? Well there is an offshoot of the vagus nerve called the recurrent laryngeal nerve. This nerve wraps around the aorta near the base of the heart on the left side of the chest and subclavian artery on the right side of the heart. The recurrent laryngeal nerve then finds the trachea to travel back up to the neck to the larynx where it innervates most of the laryngeal muscles involved with opening the airways during breathing.

Pathology

Traditional pathologising of larygeal paralysis has focussed on the recurrent laryngeal branch of the vagus. Certainly a tumour in the cranial mediastinum or the base of the heart may impact this branch of the vagus and cause problems with larynx function.

I think we have traditionally forgotten about the rest of the vagus nerve that runs all the way from the brain to the abdomen. The gut brain connection is well researched now. I'd like to propose a gut larynx connection as well. Throw our gut microbiome out of kilter and not only will you reduce function of the brain but also the larynx.

I'd also like us to think about what other pain points could go wrong here in terms of anatomy? When the nerve exits the back of the head any issues with vertebral alignment - especially the occiput, C1, C2, may affect optimal function of the vagus nerve (not only breathing but also digestion).

The vagus also passes right past the medial retropharyngeal lymphnode under the C1 vertebrae that drains all lymph from the head. Potentially if you have enlargement of this node it could physically impact the nerve. So anything the predisposes dogs to enlarged lymph nodes of the head - dental disease, ear infections etc could theoretically alter vagus function.

The thoracic inlet is prone to being very tight in lots of older dogs, chiropractic issues at the base of the neck, 1st rib, muscle tightness may also impact nerve function. As the nerve continues into abdomen through the diaphragm a tight diaphram could restrict the nerve. It is also heading through the mediastinum which is all fascia. If we are dehydrated and have tight ventral fascial lines that run all the way from the back foot to the jaw this may reduce function of these nerves.

Additionally, anything that affects nerve function needs to be looked at from a dietary sufficiency point of view - B vitamins, omega 3 fatty acids, choline (the vagus is a predominantly parasympathetic nerve with acetylcholine used as a neurotransmitter). Also optimal glide and function of fascia that the nerve sits in so hydration will be important here too.

Holistic treatment of Geriatric Onset Laryngeal Paralysis and Polyneuropathy

Not everything mentioned below will be applicable to every dog - careful assessment of each patient and household will help to work out which might be more suitable for each dog.

Surgery

Holistic treatment includes standard veterinary treatments so lets put the laryngeal tie back in here as an option for some dogs.

Acupuncture

There are various acupuncture options that help to improve the recurrent laryngeal nerve function. Mostly this has traditionally talked about using local points along the throat and larynx. Electroacupuncture (connecting needles up to a electrical stimulator) and aquapuncture (injection of a longer acting liquid into acupuncture points - often B12) are commonly discussed by holistic veterinarians. I'd like to go one step further here and also add points that support the whole digestive system like the masterpoint for stomach ST36, digestive points along the back bladder channel and possibly spleen points depending on the patient.

Laser

Laser can also be used to stimulate the recurrent laryngeal nerve similar to acupuncture above.

Biomechanical treatments

A chiropractic/osteopathic assessment can help to ensure the top of the neck where the vagus exits the skull, the base of neck and thoracic inlet, diaphagm and ventral line fascia are all moving optimally.

Rehabilitation

We can use rehabiliation to support the areas above. Walking should not be underestimated in its ability to help to move lymph and get the fascia gliding. Side stretches of neck, massage around the base of the neck and through to the diaphram and abdomen can also help.

To improve lymph flow through the medial retropharyngeal lymph node the pump action of chewing may facilitate this. Giving appropriate sized bones for dogs will help to prevent dental disease, exercise the jaw and facial muscles as well as act as a mechanical lymphatic pump to drain the head.

Microbiome

I'm starting to see a pattern of older dogs that develop laryngeal paralysis soon after an antibiotic course. I believe this to be due to a proposed gut/brain/larynx connection. So re-establishing a healthy microbiome will be an essential part of rehabilitation in dogs with antibiotic use, or general unhealthy gut function.

Diet always underlies a healthy microbiome. A minimally processed diet is what I recommend and is again tailored to the dog and household. Some older dogs will do better on cooked food diets. These can be home prepared or there are also some good commercial options these days too. You do need to work with a holistic vet or nutritionist to ensure all nutrients are being provided.

For a healthy microbiome we need some fibrous material in the diet as a pre-biotic for our gut bacteria to eat and digest. We may also need to work with probiotics. Whilst I don't do faecal microbial transfers (being a mobile vet) I do recommend referrals to vets that have tested donor dogs for this minimally invasive and effective technique.

Nutrition

Again a minimally processed real food diet is ideal here. We want to make sure that it has all the essential nutrients that is required for the body, nerves and muscles to function optimally.

When working with any nerve issue I like to make sure we have sufficient B vitamins in the diet, and also that the dog in question is able to absorb those B vitamins. Many dogs with compromised intestinal function may not be able to absorb their vitamins so we go back to the point above with microbiome.

Again looking at any nerves we want to make sure we have sufficient omega 3 fatty acids in the diet. Omega 3 supports the myelin sheath, nerve function and repair. Acetyl L Carnitine can also be used to improve energy production of nerves.

We need to make sure that we optimise our electroytes and hydration for optimal nerve, muscle and fascia function.

Herbal therapies

These are always tailored to the patient and other issues that may be going on with the dog. However consider gut function again with herbal therapies. Also anything that improve nerve function - lions mane mushrooms, ginko, bacopa.