Chondropathy, Cictraix and a Second Career for Madonna

A permanent tracheostomy bypasses a mare's damaged airway, enabling her to show a young rider the ropes.
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When all the broodmares at Jamie Steiner's family ranch came down with a respiratory bug in the spring of 2003, she wasn't terribly concerned. "None of them seemed very sick. They didn't have a fever, they were just all a bit snotty and coughing," she says. "It's the sort of thing that runs through a herd in a week or two on its own."

Permanent tracheostomies can open a horse's damaged airways enough to allow for a return to strenuous exercise. Photo © EQUUS Magazine. All Rights Reserved

Permanent tracheostomies can open a horse's damaged airways enough to allow for a return to strenuous exercise. Photo © EQUUS Magazine. All Rights Reserved

Sure enough, most of the 30 mares recovered quickly. One, however, did not. Madonna, an 11-year-old sorrel Quarter Horse, continued to have trouble breathing. The mare had been a successful barrel competitor in her younger days, then spent a few years doing ranch work before becoming part of the broodmare band. She was carrying her second foal and had never had any health issues.

But now, a week after the rest of the herd had recovered from the bug, the mare's breathing "just got worse and worse, and louder and louder," says Steiner. Clearly, something was seriously wrong, so Steiner loaded Madonna for the 20-minute trip to Elgin Veterinary Hospital in Elgin, Texas, for evaluation by Tommy Hays, DVM. The trip would save the mare's life.

Hays knew Madonna was in distress before he even saw her. "You could hear her coming, wheezing with every breath," he says. Hays began his workup with an endoscopic examination---he slipped a long probe with a light and camera up a nostril and into the mare's airways to get a look at what might be going on. Steiner, looking over Hays's shoulder, says that even with her untrained eyes, the problem was immediately obvious once the probe reached the mare's larynx: "[Instead of an open airway] she was breathing through a slit that was a little over half an inch high and looked to me like the width of a quarter."

The problem, Hays explained, was called arytenoid chondropathy, the inflammation and swelling of the cartilage "flaps" on either side of the larynx. The larynx, sometimes called the voice box, is the structure at the opening of the trachea, the flexible tube that leads to the lungs; the arytenoid cartilages normally open and close over the trachea as a horse breathes and also as he swallows, to prevent food or water from being drawn into his lungs. But when those cartilages become inflamed, Hays explains, "they swell to the point they cannot move, and they block the airway."

Unilateral chondropathy---the swelling of only one cartilage flap---is most common. This condition might make a horse whistle slightly as he breathes, but he will usually appear normal when he isn't working. Madonna, however, had bilateral chondropathy: Both of her cartilages were swollen and immobile, and even as she stood still she was struggling to breathe, with a loud and disturbing rasping sound. "The noise we were hearing was her trying to pull air past this mechanical obstruction across her larynx," says Hays.

Why Madonna alone among all of her herd developed arytenoid chondropathy is anyone's guess. "Nobody really knows exactly what causes it," Hays says. "We've seen it for years and years in our region. It's thought that it may be a type of irritant or fungus on the grass because almost 100 percent of these horses that develop this are kept on pasture."

Madonna most likely already had some minor inflammation of her arytenoids before the respiratory illness struck her herd, Hays speculates, but because she wasn't working, she was able to cope with no outward signs of trouble. The stress of the infection, however, probably triggered the flare-up that caught Steiner's attention. If it's caught in the early stages, arytenoid chondropathy can sometimes be reversed or at least improved with medications, and surgery to remove a portion of the affected cartilage may be effective, especially if only one side is affected. But not only was Madonna's case bilateral and severe, a complicating factor had already set in: scar tissue, known as cicatrix. Normally, cicatrix forms when new connective tissue closes over a wound, but in the case of chronic inflammation of the arytenoids, it can develop as a ring around the rim of the trachea that advances to close in on the larynx. No medication will reduce this scar tissue, and surgery to remove it isn't effective.

On the monitor, Hays showed Steiner the extensive cicatrix formation that was adding to the roadblock in the mare's airways. As Madonna struggled to breathe, Hays explained the implications of all of this to Steiner. Left untreated, Madonna might be able to manage on limited air intake for now, but on the first hot day of the year, or when she delivered her foal, she would be so deprived of oxygen that she would most likely die.

Only one treatment could be effective: Hays said he could perform a permanent tracheostomy, to open a hole into the mare's windpipe through the underside of her neck. She could breathe through this hole, bypassing her inflamed, scarred larynx, for the rest of her natural life.

Free and clear
Steiner didn't hesitate to approve the surgery. "The option was have her die in a few days or weeks or give her a chance to live," she says. "It wasn't a difficult decision." With the go-ahead, Hays made preparations to perform the procedure immediately. The mare was sedated and numbed with a nerve block, then the veterinarian made a five-inch incision on the underside of her neck and removed a thin layer of muscle lying between the skin and trachea. The trachea consists of a series of cartilaginous rings held together with softer connective tissue lined with mucous membrane; this structure allows it to flex with the neck while also retaining enough rigidity to prevent it from collapsing as the horse moves.

Hays removed the lower portion of four consecutive tracheal rings. "We'll cut right in the middle of each ring and we take out basically a quarter on each side," he says. The resulting hole, called a stoma, would be large enough for a relatively inactive broodmare to breathe through. "If I know a horse is going to be working, I'll do a bigger hole," he explains, "but the goal is to go only as big as you need to."

As Hays worked, he was careful not to damage the mucosal tissue lining the trachea---that would be pulled out and sewn to the mare's skin to create a lining for the opening. "Tracheal tissue doesn't granulate to heal over like skin or muscle will, so you have to line the opening with the tissue for it to stay open," he explains. "Otherwise, the hole will simply heal right over again."

Tracheal tubes are sometimes used as temporary fixes for horses who can't breathe in emergency situations, but says Hays, they can become clogged or dislodged, and the hole will begin to heal over as soon as they are removed. Madonna stopped wheezing and struggling to breathe as soon as the hole was open, even as Hays finished the procedure. It was obvious, too, that she was more comfortable as she recovered, and her vital signs were good. She stayed at the clinic for another two weeks to heal before being sent home.

Special considerations
Caring for a horse with a permanent tracheostomy isn't as difficult as it might seem, but it does require a few precautions. When Steiner arrived to retrieve Madonna, Hays explained the instructions: "There's usually some discharge around the stoma. The cells in the lining of the trachea produce mucus to help filter out dust, just as it happens at the nostrils. Instead of being at the nose, however, that discharge forms around the stoma. It can be a little unsightly but can just be wiped away."

Surprisingly, Madonna wouldn't be any more susceptible to pneumonia or respiratory irritation than other horses. "I'm always surprised at how well these horses do," says Hays. "You'd think they'd be sucking up dirt and flies and everything, but the body adapts amazingly well, and the cilia [slender , mobile, hairlike projections] that line the trachea still work to keep particles from being pulled into the lungs. I've done dozens of these, and none of the horses seem to be at a greater risk of respiratory infections."

Madonna did, however, face one big risk: "The biggest change is these horses cannot be turned out with any type of water source they can wade into, like a large tank or creek," Hays says. "The water will just pour into the hole and drown them immediately." The broodmare field at the family ranch had a large pond, so Steiner made arrangements for Madonna and another mare to live in paddock closer to the barn, with a small, standard water tank. "I was worried she'd be upset about leaving the herd, but she really didn't seem to care at all," Steiner says.

Two months after returning home Madonna delivered a healthy colt, and over the next five years, she had two more foals, with no complications from her stoma.

A second calling
Madonna's life story took another turn when she was 16. Steiner's daughter, Steely, had just turned 7 and was ready to move from her barrel pony to a bigger, more athletic horse. "Thinking about options for Steely, I kept coming back to Madonna," says Steiner.

"She was always special to every--body in the family. She started out as my mother-in-law's horse. I started rodeoing on her---I used her as my backup horse. She just was so reliable---there were times when I had to literally throw my saddle on Madonna and run back to the arena to run barrels on her. Racing straight into an arena she'd never been in her life, she would just work."

Madonna was also extremely responsive, light and well-broke. "I wanted my daughter to be able to learn on a horse who was that correct, so she'd always know how a horse is supposed to ride," says Steiner, who tacked up Madonna one day to see if she was still as terrific as she remembered. She was.

Steely started taking Madonna to competitions. "There was a transition period, for sure," Steiner says. "At first they would just trot the patterns, with Steely being cautious and probably a little frustrated. And then one day they loped it. Steely's eyes got big when she heard how fast her time was. Next time out, they just ran and it was incredible." The pair was as well-matched as Steiner had hoped.

There was, however, one problem. "As Madonna and Steely went faster, it became apparent that the stoma wasn't working well enough," says Steiner. "When the mare would breathe heavily, the sides of the stoma would get sucked in and stick together, closing off her airway." The hole that had met Madonna's needs as a broodmare wasn't large enough for her new career.

Steiner called Hays and he suggested bringing the mare in for a revision surgery. This time, Hays removed the bottom portion of an additional two tracheal rings and widened the stoma. The hole was now roughly the size of a pear, which Hays knew from experience would allow her to exert herself enough for barrel racing. Two weeks later, the mare returned home.

Today, Steely and Madonna continue to compete, and they make only a few accommodations for the mare's unusual airway. Steiner applies an aloe vera gel or petroleum jelly to the edges of Madonna's stoma if it seems to get too dry. Also, after a hard workout, Steely immediately leads Madonna to graze or eat from a bucket placed on the ground. Lowering the mare's head this way seems to open the stoma a bit, allowing her to catch her breath more quickly.

The hole in Madonna's neck may be unsightly to some people, but Steiner is grateful for the opportunity it gave both the mare and Steely: "Madonna has a job and a purpose. I'm really happy she gets to go do this stuff with my daughter. It's a special job and I think she knows it."

Hays says there is no reason Madonna can't continue to perform for many more years: "When I first started doing permanent tracheostomies, everybody thought: Ah, well, it's a salvage procedure. These horses are basically pasture animals; they can't do anything else.' But these horses, they do just fine."