Feline brachycephaly is a multifactorial syndrome leading to various clinical syndromes. Endoscopy and advanced imaging are required to fully characterize brachycephalic syndrome in cats. Recognized brachycephalic anatomy in cats includes stenotic nares, aberrant nasopharyngeal turbinates, elongated soft palate, aberrant nasolacrimal ducts, and exophthalmos.

Brachycephalic Anatomy

The most common surgically treated abnormalities in cats are stenotic nares. Surgical correction is often successful, although long-term outcomes are sparsely reported in the literature. In general, stenotic nares may occur from axial deviation of the dorsolateral ala nasi or from ventral obstruction from redundant nasal skin. Alavestibuloplasty in cats can lead to significantly improved respiratory scores, according to owner questionnaires.¹ Procedures to repair stenotic nares include alavestibuloplasty, punch resection alarplasty,² single pedicle advancement flap,³ and combined alar fold lift-up and sulcus pull-down techniques.⁴

Aberrant nasopharyngeal turbinates have been documented less frequently in cats, and the importance of this atypical pathology in cats is unknown.⁵ Similarly, elongated soft palate is rarely reported in association with clinical signs, such as activity intolerance and upper airway obstruction with secondary pulmonary edema.⁶

Skull conformation of cats with brachycephaly has been well-documented. Alterations like aberrant maxillary canine roots and shallow orbits may lead to difficulty with prehension, altered nasolacrimal ducts, increased risk of periodontal disease, and increased risk of exposure keratitis.^7,8

The constellation of abnormalities that is recognized in brachycephalic cats should be acknowledged in each individual case before considering treatment. It appears that many cats affected with stenotic nares and concurrent clinical signs of upper respiratory obstruction can benefit from surgical treatment of stenotic nares alone. That being said, the full anatomical and clinical impact of feline brachycephaly is, as of yet, still undefined, and further research in this area is indicated.

Feline Inflammatory Polyps

Feline inflammatory polyps are the second major category of benign upper airway disease in cats and a common indication for middle ear and nasopharyngeal surgery. These benign, non-neoplastic masses arise from the mucosa of the auditory (eustachian) tube and may extend into the nasopharynx, the middle ear, or both. Histologically, polyps consist of loosely arranged fibrovascular tissue covered by squamous or columnar epithelium, with a lymphoplasmacytic and monocytic inflammatory infiltrate and frequent ulceration. The underlying etiology remains unknown; proposed mechanisms include a congenital origin from branchial arch remnants and an infectious or postinflammatory origin secondary to chronic respiratory or middle ear infection. A causal link to feline calicivirus, which has been recovered from some polyps, has not been confirmed.

Polyps most commonly affect young cats, with a reported median age of onset around 1.5 years. Clinical signs depend on location and chronicity. Cats with an aural component often present with otitis, otorrhea, and head shaking and may develop neurologic signs like Horner syndrome, facial nerve paresis, ataxia, or head tilt, while nasopharyngeal extension more typically causes nasal discharge, stertorous breathing, and sneezing. Diagnosis begins with otoscopic examination and palpation or retraction of the soft palate. Computed tomography is the imaging modality of choice, typically showing a homogeneous, rim-enhancing mass with asymmetric bulla involvement.⁹ Magnetic resonance imaging is used less commonly, reserved for cases with concurrent central nervous system signs given the rare association between polyps and secondary meningoencephalitis.¹⁰

Treatment for polyps ranges from minimally invasive traction techniques to bulla osteotomy. In general, the more invasive the surgical treatment, the lower the risk of recurrence. Traction avulsion via a lateral ear canal approach is a widely used first-line technique in which the polyp is grasped and avulsed from its base within the tympanic cavity. In a study of 62 cats, recurrence was 14.3% for experienced surgeons versus 35% for less experienced surgeons, with 11.5% of cats experiencing postoperative Horner syndrome.¹¹ In another study of 37 cats, per-endoscopic transtympanic traction—a less invasive technique using endoscopic guidance—achieved resolution in the majority of patients, with recurrence in 13.5% and Horner syndrome in 8%.¹²

Ventral bulla osteotomy (VBO) is reserved for polyps with substantial middle ear involvement, recurrence after traction, or cases warranting bulla exploration and culture. VBO is the most invasive option but carries a lower recurrence risk than traction-based techniques.¹³ The cat is positioned in dorsal recumbency with the neck extended. A paramedian incision is made over the palpable ventral bulla, between the wing of the atlas and the mandible’s angular process. Dissection proceeds bluntly to the bulla, and an osteotomy is performed in the larger ventromedial compartment and enlarged with rongeurs. Because most polyps arise from the smaller dorsolateral compartment, the bony septum between the two chambers is removed to access the polyp’s origin. The oval promontory, where sympathetic fibers controlling pupillary and eyelid tone traverse the middle ear, is avoided.¹³

Horner syndrome is the most frequent VBO complication due to injury to these sympathetic fibers. In one study, Horner syndrome developed in 43% of cats managed with traction alone versus 57% treated surgically.¹⁴ Signs typically resolve within weeks to months, and aggressive curettage near the dorsomedial bulla should be avoided to limit this risk.¹³ Facial nerve paralysis and vestibular signs are less common. One study using brainstem auditory evoked response testing found no significant change in hearing after VBO, and cats who were deaf preoperatively did not regain hearing—suggesting that associated hearing loss is more often sensorineural than conductive.¹⁵ The most serious complication is postoperative respiratory distress, which is more frequent after single-stage bilateral VBO than unilateral or staged procedures. In one series of nearly 300 cats, roughly one-third of those with postoperative respiratory signs died or were euthanized within five days, underscoring the need for careful staging in bilateral cases.¹⁶ Recurrence after VBO is uncommon and generally lower than with less invasive approaches.

As with feline brachycephaly, management of inflammatory polyps continues to evolve, and the choice between traction-based techniques and VBO should be individualized based on middle ear involvement, recurrence history, and the risks the owner and surgeon accept.

Dr. Gibson’s presentations at the 2026 CVMA Fall Seminar will focus on small animal soft tissue surgery.