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Topic:Larynx

The larynx in horses is a complex anatomical structure located in the throat, playing a critical role in respiration, phonation, and airway protection. It consists of cartilages, muscles, and ligaments that work together to regulate airflow into the trachea and produce vocal sounds. The equine larynx is susceptible to various conditions, such as laryngeal hemiplegia, which can impact a horse's breathing and performance. This page aggregates peer-reviewed research studies and scholarly articles that explore the anatomy, function, disorders, and clinical management of the larynx in horses, providing insights into diagnostic techniques and therapeutic interventions.
Biomechanical testing of three constructs for prosthetic laryngoplasty in horses demonstrates advantages of differing metallic implants in the arytenoid cartilage.
Veterinary surgery : VS    August 10, 2025   doi: 10.1111/vsu.14328
Ysebaert MP, Johnson J, Marie U, Campos A, Verchrerin A, Ducharme NG, Rossignol F, Luedke LK.To compare the biomechanical stability of a novel arytenoid implant (tie-bolt, TB) with a suture anchor (SA) and standard laryngoplasty using suture alone (control) in equine larynges. Methods: Randomized ex vivo controlled experimental study. Methods: Thirty equine cadaver larynges. Methods: Larynges were randomly assigned to TB, SA, or control groups (n = 10 each). The force of abduction was measured for each construct, then constructs underwent cyclic loading (5-50 N for 3000 cycles) to assess elongation, followed by load-to-failure testing to assess ultimate load, displacement, stiffn...
Retrospective radiographic myelogram measurements and long-term outcomes in horses undergoing cervical interbody fusion surgery: 22 cases.
PloS one    May 7, 2025   Volume 20, Issue 5 e0323083 doi: 10.1371/journal.pone.0323083
England D, Newsom L, White C, McKenzie E.Site selection for cervical stabilization surgery in horses with spinal ataxia frequently relies on measurements derived from radiographic myelography. A variety of measurement criteria exist and can provide conflicting results. The main objectives of this study were to assess the correlation between two commonly used myelographic measures, dorsal contrast column reduction (DCCR) and dural diameter reduction (DDR), and their association with previously selected operative sites in a population of horses operated at a tertiary clinic. Secondary objectives were to determine if articular process j...
Equine upper airway laser surgery generates plumes containing hazardous components.
American journal of veterinary research    February 6, 2025   1-6 doi: 10.2460/ajvr.24.11.0338
Sholty KA, Hecobian A, Sullivan AP, Collett JL, Koch DW, Hackett ES.To evaluate plume composition during simulated diode laser equine upper airway surgery. Unassigned: A 980-nm diode laser fiber was applied in continuous-wave mode in contact with laryngeal and pharyngeal tissues of 6 equine cadaver heads, and resultant plumes were collected for analysis. Measured parameters included the real-time concentration of particulate matter under the size of 2.5 μm (PM2.5), organic carbon (OC), elemental carbon (EC), and volatile organic compounds (VOCs). Unassigned: Visible smoke was encountered during surgical laser application and plume collection. Diode laser medi...
Yearling laryngeal function grades II.2 and below are not associated with reduced performance.
Equine veterinary journal    January 21, 2025   Volume 57, Issue 4 953-966 doi: 10.1111/evj.14452
Hardwick JL, Ahern BJ, Crawford KL, Allen KJ, Anderson BH, Rose KJ, Franklin SH.The relationship between Thoroughbred yearling laryngeal function (YLF) grade and race performance is unclear. Objective: To determine the effect of YLF on future race performance. Methods: Retrospective cohort study. Methods: Post-sale endoscopic recordings were reviewed from Australian yearling sales in 2018-2019. Race performance was evaluated for career and as 2-, 3- and ≥4-year-olds. Multivariable generalised linear modelling examined the association between YLF and performance, with risk estimates presented as coefficients (95% CI). Results: The YLF in 5175 examinations was graded I in...
A genome-wide association study for recurrent laryngeal neuropathy in the Thoroughbred horse identifies a candidate gene that regulates myelin structure.
Equine veterinary journal    January 10, 2025   doi: 10.1111/evj.14461
McGivney CL, McGivney BA, Farries G, Gough KF, Han H, Holtby AR, MacHugh DE, Katz LM, Hill EW.Equine recurrent laryngeal neuropathy (RLN) is an economically important upper respiratory tract (URT) disease with a genetic contribution to risk, but genetic variants independent of height have not been identified for Thoroughbreds. The method of clinical assessment for RLN is critical to accurately phenotype groups for genetic studies. Objective: To identify genetic risk loci for RLN in Thoroughbreds in a genome-wide association study (GWAS) following high-resolution phenotyping. Methods: Case-control. Methods: Thoroughbred horses were characterised as RLN cases and controls using resting a...
Comparative analysis of racing performance following surgical correction of epiglottic entrapment in standardbreds and thoroughbreds.
Frontiers in veterinary science    November 19, 2024   Volume 11 1479144 doi: 10.3389/fvets.2024.1479144
Norton AM, Rosanowski SM, O'Brien T.Epiglottic entrapment (EE) is a common cause of poor performance in racing standardbreds (STBs) and thoroughbreds (TBs). There is limited information published on the condition in STB racehorses and limited information on factors associated with return to racing available for either breed. Unassigned: This study investigated and compared the pre surgical findings, post-surgical complications and racing performance in STBs and TBs undergoing surgery for correction of EE. Associations between signalment and pre-surgical findings, and the presence of complications and racing post-surgery were com...
A first step towards objective grading of equine laryngeal function.
Veterinary journal (London, England : 1997)    October 26, 2024   Volume 308 106259 doi: 10.1016/j.tvjl.2024.106259
Hardwick J, Ahern B, Franklin S.Due to concerns about disagreement between veterinarians when grading resting laryngeal function (LF), a diagnostic decision tree (DDT) has been developed by codifying the Havemeyer grading system and objectively defining certain terms to remove ambiguity. Videoendoscopic examinations of the equine larynx that had previously been assigned a unanimous LF grade by 3 experienced observers were used to develop the DDT and determine the cut-off values. The DDT is a flow chart consisting of a series of dichotomous (yes/no) decisions, to dictate the order of decision making and direct the observer do...
Explainable machine learning for assessing upper respiratory tract of racehorses from endoscopy videos.
Computers in biology and medicine    August 21, 2024   Volume 181 109030 doi: 10.1016/j.compbiomed.2024.109030
Tahir AM, Guo L, Ward RK, Yu X, Rideout A, Hore M, Wang ZJ.Laryngeal hemiplegia (LH) is a major upper respiratory tract (URT) complication in racehorses. Endoscopy imaging of horse throat is a gold standard for URT assessment. However, current manual assessment faces several challenges, stemming from the poor quality of endoscopy videos and subjectivity of manual grading. To overcome such limitations, we propose an explainable machine learning (ML)-based solution for efficient URT assessment. Specifically, a cascaded YOLOv8 architecture is utilized to segment the key semantic regions and landmarks per frame. Several spatiotemporal features are then ex...
Do tight nosebands have an effect on the upper airways of horses?
Veterinary medicine and science    June 17, 2024   Volume 10, Issue 4 e1478 doi: 10.1002/vms3.1478
Scholler D, Wittenberg J, Zablotski Y, May A.The public perception relating to the welfare of horses involved with equestrian sports is associated with training methods used and the presentation of horses at events. In this context, very tight nosebands, which are intended to prevent the horse from opening its mouth, also attract a lot of attention. Various studies have evaluated the impact of tight nosebands on stress parameters, whereas the effect of tight nosebands on upper airway function is unknown. Therefore, the aim of the study was to use overground endoscopy to evaluate changes in pharyngeal and laryngeal function when a tight n...
Enhancing prosthesis stability at the cricoid cartilage in equine laryngoplasty using 3-D-printed laryngeal clamps: An ex vivo model study.
Veterinary surgery : VS    June 5, 2024   doi: 10.1111/vsu.14115
Grzeskowiak R, Schumacher J, Omidi O, Bowers K, Cassone LMC, Abedi R, Hespel AM, Mulon PY, Anderson DE.To assess a three-dimensional (3-D)-printed laryngeal clamp (LC) designed to enhance the anchoring of laryngeal prostheses at the cricoid cartilage. Methods: Ex vivo biomechanical study. Methods: A total of 22 equine larynges. Methods: Two experimental groups included larynges with standard prosthetic laryngoplasty (PL; n = 10) and larynges with prosthetic laryngoplasty modified with laryngeal clamps (PLLC; n = 10). All constructs underwent 3000 cycles of tension loading and a single tension to failure. Recorded biomechanical parameters included maximum load, actuator displacement, a...
Computational fluid dynamic analysis of upper airway procedures in equine larynges.
Frontiers in veterinary science    April 17, 2023   Volume 10 1139398 doi: 10.3389/fvets.2023.1139398
Tucker ML, Wilson DG, Bergstrom DJ, Carmalt JL.Computational fluid dynamics (CFD) has proven useful in the planning of upper airway surgery in humans, where it is used to anticipate the influence of the surgical procedures on post-operative airflow. This technology has only been reported twice in an equine model, with a limited scope of airflow mechanics situations examined. The reported study sought to widen this application to the variety of procedures used to treat equine recurrent laryngeal neuropathy (RLN). The first objective of this study was to generate a CFD model of an box model of ten different equine larynges replicating RLN a...
A biomechanical comparison of a novel two-loop suture technique and two sutures for laryngoplasty in the horse.
American journal of veterinary research    March 7, 2023   Volume 84, Issue 5 ajvr.22.11.0189 doi: 10.2460/ajvr.22.11.0189
Wilson DG, Roquet I, Tucker ML, Carmalt JL.Evaluation of the strength of the novel suture technique by comparison with a 2-interrupted suture technique. Methods: 40 equine larynges. Methods: 40 larynges were used; 16 laryngoplasties were performed using the currently accepted 2-suture technique and 16 using the novel suture technique. These specimens were subjected to a single cycle to failure. Eight specimens were used to compare the rima glottidis area achieved with 2 different techniques. Results: The mean force to failure, as well as the rima glottidis area of both constructs, were not significantly different. The cricoid width did...
Corrigendum to “Implications of different degrees of arytenoid cartilage abduction on equine upper airway characteristics”.
Equine veterinary journal    December 9, 2022   Volume 55, Issue 2 344 doi: 10.1111/evj.13901
No abstract available
Tongue ties do not widen the upper airways in racehorses.
Equine veterinary journal    September 14, 2022   Volume 55, Issue 4 642-648 doi: 10.1111/evj.13867
Barton AK, Troppenz A, Klaus D, Lindenberg I, Merle R, Gehlen H.There is contradictory evidence on the potential benefits of tongue ties on upper airway function and their efficacy in inhibiting intermittent dorsal displacement of the soft palate (DDSP) in racehorses. Objective: To test the hypothesis that tongue ties increase the pharyngeal diameter and decrease the occurrence of dynamic airway obstruction in racehorses. Methods: Prospective, crossover blinded clinical study. Methods: Data of 22 Thoroughbred and 8 Standardbred racehorses examined using overground endoscopy under full-intensity exercise on training racetracks with and without fixation of t...
The effect of repeated freezing and thawing on the suture pull-out strength in equine arytenoid and cricoid cartilages.
Veterinary surgery : VS    July 11, 2022   Volume 51, Issue 7 1106-1110 doi: 10.1111/vsu.13855
Gray SM, Gutierrez-Nibeyro SD, Horn GP, McCoy AM, Schaeffer DJ, Stewart M.To assess the effect of repeated freezing and thawing on the suture pull-out strength in arytenoid and cricoid cartilages subjected to the laryngoplasty (LP) procedure. Methods: Ex vivo experimental study. Methods: Ten grossly normal equine cadaveric larynges. Methods: Bilateral LP constructs were created using a standard LP technique. One hemilarynx was randomly allocated to the single freeze and thaw group and the other allocated to the repeated freeze and thaw (3 complete cycles) group. The suture ends of each LP construct were attached to a load frame and subjected to monotonic loading unt...
Influence of unilateral and bilateral vocal cordectomy on airflow across cadaveric equine larynges at different Rakestraw grades of arytenoid abduction.
Veterinary surgery : VS    May 24, 2022   Volume 51, Issue 6 974-981 doi: 10.1111/vsu.13823
Lean NE, Bertin FR, Ahern BJ.To assess the effect of vocal cordectomy on airflow across equine larynges at different Rakestraw grades of arytenoid abduction using a unidirectional airflow model. Methods: Ex vivo, repeated measures. Methods: Twenty cadaveric equine larynges. Methods: The right arytenoid cartilage was maximally abducted in all larynges. Each larynx was assigned a Rakestraw grade A or B, and the left arytenoid was abducted accordingly. Each larynx was tested under 3 conditions: intact, left vocal cordectomy (LVC), and bilateral vocal cordectomy (BVC). Translaryngeal pressure and airflow were measured, and di...
Effect of a combination of butorphanol and detomidine on endoscopic assessment of laryngeal function in Thoroughbred yearlings.
The Veterinary record    March 29, 2022   Volume 190, Issue 9 e1483 doi: 10.1002/vetr.1483
Almonte H, Schumacher J, Johnson CR, Berk JT, Bell RP.To the authors' knowledge, the effect of a combination of butorphanol tartrate and detomidine hydrochloride on the laryngeal function and symmetry of the arytenoid cartilages in young Thoroughbred horses has not been examined. Therefore, this study aimed to examine the effects of administration of butorphanol and detomidine on left-to-right rima glottidis ratio (L:R RGR), cross-sectional area of the rima glottidis (CSARG) and grade of laryngeal function of Thoroughbred yearlings examined endoscopically at rest. Forty-six Thoroughbred yearlings underwent laryngeal video endoscopy, at rest, befo...
Evaluation of postsale endoscopy as a predictor of future racing performance in an Australian thoroughbred yearling population.
Australian veterinary journal    February 21, 2022   Volume 100, Issue 6 254-260 doi: 10.1111/avj.13155
Ahern BJ, Sole A, de Klerk K, Hogg LR, Vallance SA, Bertin FR, Franklin SH.Upper airway endoscopy of thoroughbred (TB) yearlings is commonly used in an attempt to predict laryngeal function (LF) and its impact on future race performance. The aim of this study was to determine if different grading systems and laryngeal grades were correlated with future performance. Methods: Postsale endoscopic recordings were obtained from an Australian TB yearling sale during a four-year period from 2008 to 2011. Horses were included if they had a diagnostic postsale video endoscopic recording and raced within Australia. Recordings were graded using the Havemeyer system and subseque...
Computed tomographic geometrical analysis of surgical treatments for equine recurrent laryngeal neuropathy.
American journal of veterinary research    February 8, 2022   Volume 83, Issue 5 443-449 doi: 10.2460/ajvr.21.03.0040
Tucker ML, Wilson DG, Reinink SK, Carmalt JL.To characterize the 3-D geometry of the equine larynx replicating laryngeal hemiplegia and 4 surgical interventions by use of CT under steady-state airflow conditions. Secondly, to use fluid mechanic principles of flow through a constriction to establish the relationship between measured airflow geometries with impedance for each surgical procedure. Methods: 10 cadaveric horse larynges. Methods: While CT scans were performed, inhalation during exercise conditions was replicated for each of the following 5 conditions: laryngeal hemiplegia, left laryngoplasty with ventriculocordectomy, left lary...
Ex vivo biomechanical evaluation of polyester and polyblend suture techniques to perform equine laryngoplasty.
Veterinary surgery : VS    February 7, 2022   Volume 51, Issue 3 497-508 doi: 10.1111/vsu.13777
Pressanto MC, Pascoletti G, Perkins JD, Zanetti EM, Beccati F, Santalucia V, Pepe M.To validate the use of a polyblend tape suture in equine laryngoplasty (PL). Methods: Experimental study. Methods: Thirty-two cadaveric larynges. Methods: Each larynx was randomly assigned to 1 of 4 groups: PL with polyblend tape suture (TigerTape), without (TT) or with a cannula (TTC) in the muscular process of the arytenoid cartilage, and PL with polyester suture (Ethibond), without (EB) or with a cannula (EBC). Construct stiffness, total migration, creep, and drift values were measured after 3000 cycles. The specimens were then loaded to failure to assess their residual properties: load a...
Impact of endotracheal tube size and cuff pressure on tracheal and laryngeal mucosa of adult horses.
Veterinary anaesthesia and analgesia    September 16, 2021   Volume 48, Issue 6 891-899 doi: 10.1016/j.vaa.2021.08.046
Ferreira TH, Allen M, De Gasperi D, Buhr KA, Morello SL.To assess the effects of two sizes of silicone endotracheal tubes with internal diameter 26 mm (ETT) and 30 mm (ETT) inflated to minimum occlusive volume on tracheal and laryngeal mucosa of adult horses anesthetized for 2 hours with isoflurane. Methods: Prospective, randomized, blinded, crossover experimental study. Methods: A total of eight healthy adult mares. Methods: Upper airway endoscopy and ultrasound measurements of internal tracheal diameter were performed the day before anesthesia. Horses were anesthetized and orotracheally intubated with ETT or ETT. Ease of intubation was scored. Th...
Evaluation of the airway mechanics of modified toggle laryngoplasty constructs using a vacuum chamber airflow model.
Veterinary surgery : VS    July 26, 2021   Volume 50, Issue 7 1409-1417 doi: 10.1111/vsu.13690
Gray SM, Gutierrez-Nibeyro SD, Couëtil LL, Horn GP, Kesler RM, McCoy AM, Stewart MC, Schaeffer DJ.To evaluate the airway mechanics of modified toggle LP constructs in an airflow chamber model and compare these to the airway mechanics of standard LP constructs. Methods: Ex-vivo experimental study. Methods: Fifty-one equine cadaveric larynges. Methods: Bilateral LP constructs were performed using a modified toggle (n = 23) or a standard (n = 21) LP technique. Constructs were tested in an airflow model before and after cyclic loading which was designed to mimic postoperative swallowing. The cross-sectional area (CSA), peak translaryngeal airflow (L/s), and impedance (cmH 0/L/s) were deter...
Development of a constant pressure perfused ex vivo model of the equine larynx.
PloS one    May 20, 2021   Volume 16, Issue 5 e0251530 doi: 10.1371/journal.pone.0251530
Otto S, Michler JK, Dhein S, Mülling CKW.Distal axonopathy is seen in a broad range of species including equine patients. In horses, this degenerative disorder of the recurrent laryngeal nerve is described as recurrent laryngeal neuropathy (RLN). The dysfunctional innervation of the cricoarytenoideus dorsalis muscle (CAD) leads to a loss of performance in affected horses. In general, ex vivo models of the larynx are rare and for equine patients, just one short report is available. To allow for testing new therapy approaches in an isolated organ model, we examined equine larynges in a constant pressure perfused setup. In order to chec...
Epithelial to Mesenchymal Transition (EMT) in a Laryngeal Squamous Cell Carcinoma of a Horse: Future Perspectives.
Animals : an open access journal from MDPI    December 7, 2020   Volume 10, Issue 12 2318 doi: 10.3390/ani10122318
Armando F, Godizzi F, Razzuoli E, Leonardi F, Angelone M, Corradi A, Meloni D, Ferrari L, Passeri B.Squamous cell carcinoma (SCC) is one of the most frequent tumors of skin and muco-cutaneous junctions in the horse. Equine papillomavirus type 2 (EcPV2) has been detected in equine SCC of the oral tract and genitals, and recently also in the larynx. As human squamous cell carcinoma of the larynx (SCCL), it is strongly etiologically associated with high-risk papillomavirus (h-HPV) infection. This study focuses on tumor cells behavior in a naturally occurring tumor that can undergo the so-called epithelial to mesenchymal transition (EMT). A SCCL in a horse was investigated by immunohistochemistr...
Clinical and Pathological Features in Horses With Advanced Arytenoid Chondritis.
Veterinary pathology    November 18, 2020   Volume 58, Issue 1 91-102 doi: 10.1177/0300985820967452
Bolfa P, Cercone M, Dennis MM, Conan A, Grevemeyer B, Ducharme NG.Equine arytenoid chondritis causes airway obstruction and abnormal upper airway noise due to a space-occupying lesion(s) and decreased abduction. Our objective was to compare clinical scores and ultrasonographic findings with gross and microscopic lesions of naturally occurring arytenoid chondritis, in order to guide surgical treatment. Seventeen naturally affected horses with advanced/severe chronic arytenoid chondritis and 4 control arytenoid cartilages were evaluated after partial arytenoidectomy. Cartilages were sectioned caudal to the corniculate process and the body of each arytenoid was...
Thyrohyoideus muscle innervation in the horse.
Veterinary surgery : VS    November 6, 2020   Volume 50, Issue 1 53-61 doi: 10.1111/vsu.13536
Genton M, Robert C, Jerbi H, Huet H, Cordonnier N, Vitte-Rossignol A, Perkins JD, Rossignol F.To describe the innervation of the thyrohyoideus (TH) muscle and to confirm our findings with stimulation of first cervical (C1) nerve branches. Methods: Ex vivo phase 1 and clinical phase 2. Methods: Fourteen head and neck specimens and 17 client-owned horses. Methods: In phase 1, the cranial nerve (CN) XII and the C1 nerve were dissected with their branches in 20 dissections were performed on 14 specimens (6 left and right side and 8 only left or right) Anatomy was noted. Samples of nerve bifurcations were collected for histological confirmation of anatomical findings. First cervical nerve b...
Ex vivo modeling of the airflow dynamics and two-and three-dimensional biomechanical effects of suture placements for prosthetic laryngoplasty in horses.
American journal of veterinary research    July 24, 2020   Volume 81, Issue 8 665-672 doi: 10.2460/ajvr.81.8.665
Lynch NP, Jones SA, Bazley-White LG, Wilson ZF, Raffetto J, Pfau T, Cheetham J, Perkins JD.To identify the degree of left arytenoid cartilage (LAC) abduction that allows laryngeal airflow similar to that in galloping horses, assess 2-D and 3-D biomechanical effects of prosthetic laryngoplasty on LAC movement and airflow, and determine the influence of suture position through the muscular process of the arytenoid cartilage (MPA) on these variables. Methods: 7 equine cadaver larynges. Methods: With the right arytenoid cartilage maximally abducted and inspiratory airflow simulated by vacuum, laryngeal airflow and translaryngeal pressure and impedance were measured at 12 incremental LAC...
Ex-vivo Mechanical Testing of Novel Laryngeal Clamps Used for Laryngeal Advancement Constructs.
Frontiers in veterinary science    March 12, 2020   Volume 7 139 doi: 10.3389/fvets.2020.00139
Grzeskowiak RM, Schumacher J, Mulon PY, Steiner RC, Cassone L, Anderson DE.Rostral laryngeal advancement, also known as laryngeal tie-forward, is used to treat horses for intermittent dorsal displacement of the soft palate and has a morbidity rate of about 6%. We hypothesized that a novel laryngeal clamp would prevent morbidity associated with the sutures tearing through the thyroid cartilage. Larynges (n = 35 horses) were used for ex vivo testing. For uniaxial testing, 15 equine larynges were tested in one of three laryngeal tie-forward constructs [standard laryngeal tie-forward; modified laryngeal tie-forward using a suture-button; and modified laryngeal tie-forwar...
External transcutaneous ultrasound technique in the equine cricoarytenoideus dorsalis muscle: Assessment of muscle size and echogenicity with resting endoscopy.
Equine veterinary journal    February 6, 2020   Volume 52, Issue 4 500-508 doi: 10.1111/evj.13209
Satoh M, Higuchi T, Inoue S, Miyakoshi D, Kajihara A, Gotoh T, Shimizu Y.Recent studies have assessed the cricoarytenoideus dorsalis muscle (CAD) using transoesophageal ultrasonography in equine recurrent laryngeal neuropathy (RLN). We assessed the CAD using the external transcutaneous ultrasound technique, which may constitute an easier method in horses. Objective: To evaluate ultrasonographic imaging of the left cricoarytenoideus dorsalis muscle (LCAD) and right cricoarytenoideus dorsalis muscle (RCAD) as a diagnostic tool for RLN using the transcutaneous ultrasound technique. Methods: Cross-sectional study. Methods: The axial plane thickness, cross-sectional are...
Complete resection of the alar folds in eight standing horses with a bipolar dividing and vessel-sealing device.
Veterinary surgery : VS    February 6, 2020   Volume 49, Issue 3 521-528 doi: 10.1111/vsu.13383
Kallmyr A, Giving EM, Moen LO, Øverlie M, Holm T, David F.To describe a resection technique of the alar folds in the standing horse. Methods: Retrospective case study. Methods: Eight Standardbred racing trotters. Methods: Horses in which alar fold collapse had been diagnosed between 2017 and 2018 were included in this study. All horses underwent alar fold resection under standing sedation and regional anesthesia with a bipolar electrosurgical open sealer/divider device (LigaSure). Intraoperative and postoperative complications were recorded. A Wilcoxon signed-rank test was used to compare differences in median prize money earning pre-surgery and post...
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