AUSTRALIA’S
PREMIER VETERINARY
SCIENCE TEXT
EQUINE
Overground endoscopy in 311 Thoroughbred racehorses: findings
and correlation to resting laryngeal function
EQUINE
JA Davison,a* JM Lumsden,b RC Bostonc and BJ Ahernd
Objective To review a large number of equine overground
endoscopy (OGE) examinations to determine the incidence of
dynamic upper airway obstructions (DUAO); correlations were
explored with laryngeal endoscopy findings at rest and abnormal
exercising respiratory noise.
Methods Retrospective analysis of horses presenting for OGE
because of perceived poor performance and/or history of abnor-
mal exercising respiratory noise between 2010 and 2014. Signal-
ment, history and examination findings during resting laryngeal
endoscopy and OGE were reviewed.
Results Of the total examinations, 311 were reviewed. One or
more DUAO were found in 249/311 horses. From 210 males (colts
and geldings), 121 had arytenoid cartilage collapse (ACC) and
111 had vocal fold collapse (VFC). From 101 females, 25 had inter-
mittent dorsal displacement of the soft palate (DDSP). Resting
laryngeal function grade 4 was found in 121/311 of the study
population and 92/210 of males. An association was found
between horses with lower resting arytenoid abduction ability to
dynamic ACC and higher resting arytenoid abduction ability with
DDSP. Abnormal exercising respiratory noise was positively asso-
ciated with the presence of DUAO.
Conclusions Multiple DUAO in association with abnormal exer-
cising respiratory noise was a common finding in horses exam-
ined for poor performance. This study highlights the importance
of OGE in accurately diagnosing the nature of DUAO associated
with poor performance.
Keywords arytenoid cartilage; overground endoscopy; horses;
upper airway obstruction
Abbreviations ACC, arytenoid cartilage collapse; DDSP, dorsal
displacement of the soft palate; DUAO, dynamic upper airway
obstruction; HSTE, high-speed treadmill endoscopy; MDAF, medial
deviation of the aryepiglottic fold; NPC, nasopharyngeal collapse;
OGE, overground endoscopy; PI, palatal instability; TB,
Thoroughbred; VFC, vocal fold collapse.
Aust Vet J 2017;95:338–342 doi: 10.1111/avj.12620
D noises correlate to DDSP.6,22–24 A further aim of this study was to
ynamic upper airway obstructions (DUAO) occur when
soft tissue structures of the upper airway deform and col-
lapse as a result of airflow pressures associated with exer-
cise.1 . DUAO are commonly reported in racehorses, because of the
*Corresponding author.
a
Rossdales Equine Practice, Beaufort Cottage Stables, Newmarket, Suffolk, CB8 8JS,
UK; joshuadavison.vet@outlook.com
b
Randwick Equine Centre, Randwick, New South Wales, Australia
c
University of Pennsylvania, New Bolton Center, PA, USA
d
University of Queensland, UQ Gatton Campus, Gatton, Queensland, Australia
338 Australian Veterinary Journal Volume 95 No 9, September 2017
maximal exercise intensity associated with significant negative
inspired airway pressures.2–13
Upper respiratory tract endoscopic examination in the resting
horse does not consistently allow reproduction of the extent of
DUAO seen at exercise, principally because of the lower magni-
tude of intraluminal airway pressure changes present in the resting
versus exercising horse. Furthermore, there is a lack of repeatable
correlation with certain upper airway abnormalities seen at rest
with what occurs during exercise.2,14–20 The development of
dynamic respiratory endoscopy in horses has rapidly come to be
the ‘gold standard’ modality for diagnosing DUAO. Accurate diag-
nosis and understanding of the complexity of DUAO advanced
substantially with the use of high-speed treadmill endoscopy
(HSTE).21 More recently, the development of overground endos-
copy has enabled endoscopic examination at exercise in the
horse’s natural working environment, at the convenience of the
owner/trainer and using their own exercise facilities.5,9 An impor-
tant difference of OGE compared with HSTE is the ability to per-
form the examination to more closely replicate ‘race-like’
conditions.7,8 Comparisons between OGE and HSTE findings from
examinations suggest comparable results between the two modal-
ities, other than intermittent dorsal displacement of the soft palate
(DDSP), which is reported to be less commonly diagnosed with
OGE than with HSTE.7
Varying grades of arytenoid cartilage abduction and soft palate func-
tion at rest have established correlations with exercising laryngo-
pharyngeal function; however, to date endoscopic findings at rest
have not been well correlated with multiple (complex) forms of
DUAO experienced during exercise.2,17 One of the aims of this study
was to determine if endoscopic findings at rest correlated with the
observation of simple and complex DUAO during exercise.
Owner/trainer reporting of abnormal exercising respiratory noise
has been shown to have a high sensitivity and low specificity for the
presence of a DUAO, with variable specificity for correlating classic
noise patterns and specific airway obstructions. High-frequency
‘whistling’ and ‘roaring’ during inspiration show the highest specific-
ity for laryngeal dysfunction, whereas low-frequency expiratory
document the presence of reported abnormal exercising respiratory
noise with specific OGE findings.
This study was a retrospective analysis of OGE findings from a large
population of Thoroughbred (TB) racehorses in Australia under sim-
ilar management. For this report, we aimed to evaluate the associa-
tions between clinically relevant resting laryngeal grades and DUAO,
as well as with reported abnormal exercising respiratory noise
production.
© 2017 Australian Veterinary Association

Materials and methods
Case selection and inclusion criteria
Case records for TB horses that underwent OGE between February
2010 and March 2014 were retrieved. All cases were examined at
metropolitan and provincial racetracks by personnel from Randwick
Equine Centre, Sydney. Horses that had undergone prior upper air-
way surgery and/or previous OGE were excluded from the study.
OGE acquisition
All horses were in flatrace training, undergoing exercise intensities
consistent with speeds of 80–100% of racing speed (11–13 s/fur-
long). An overground endoscope (Dynamic Respiratory Scope V2,
Optomed, Les Ulis, France) was used for all endoscopic examina-
tions, with the resting and exercising components of the examination
performed as previously described.5,25 Briefly, the endoscope was
positioned at the level of the guttural pouch ostia to ensure the rima
glottides, corniculate processes, epiglottis and pharynx were visible.
Once the equipment was in place, laryngeal function was evaluated
at rest with stimulation of 2–3 swallows, prior to exercising on oval
racetracks over at least 1200 m.7,25 Trainers or their delegates were
required to complete a questionnaire regarding the horse’s history of
poor performance, previous conservative management or tack worn
during exercise, as well as historical presence or absence of an abnor-
mal exercising respiratory noise during work.
OGE assessment
OGE recordings were evaluated by either one of the senior authors
(JL or BA) using multimedia software (Quicktime Pro™, Apple Inc.,
CA, USA). At rest, the upper airway was examined for any abnorm-
alities and degree of soft palate function. The caudal free margin of
the soft palate was not routinely assessed. Arytenoid function at rest
was graded as per Lane from 1 to 5.26 Briefly, grade 1 indicates all
movement is symmetrical and synchronised; grade 2, major move-
ments are symmetrical and synchronous with only transient asyn-
chrony; grade 3, asymmetry of the rima glottidis because of reduced
motility of the left arytenoid, but full abduction can still be achieved;
grade 4, consistent asymmetry of the rima glottidis, but with some
residual motility of the left arytenoid cartilage; grade 5, consistent
asymmetry of the rima glottidis, with no motility of the left arytenoid
cartilage. Video from the initial ‘warm up’ trot to the end of fast
work was then analysed. Frame by frame analysis of the video
recordings were used for diagnosis of DUAO during the period of
maximal exercise (final 4 furlongs), recorded with representative still
images.25 Recordings that had poor image quality were not included
in the study.
Data analysis
Horses were grouped into male and female. The three age groupings
reflected the ages commonly examined: ≤ 2 years old, 3 years old
and ≥ 4 years old.
The DUAO were grouped into partial/complete arytenoid cartilage
collapse (ACC), intermittent dorsal displacement of the soft palate
(DDSP), vocal fold collapse (VFC), biaxial medial deviation of the
aryepiglottic folds (MDAF) and nasopharyngeal collapse
(NPC).2,27–29 All arytenoid abduction that was asymmetrical with
© 2017 Australian Veterinary Association
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the contralateral arytenoid during maximal exercise was classified
as ACC. When ACC was noted, same-side VFC was not classified
as a separate condition. Each horse’s arytenoid function at exercise
was further graded into three categories after Rakestraw et al.: A =
full laryngeal abduction during inspiration, B = between full abduc-
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tion and resting position and C = abduction is equal to or less than
resting.27 For the purposes of statistical analysis, each DUAO that
appeared in less than 2.5% of the population was classified as unu-
sual and grouped as ‘Other’, which included palatal instability (PI),
arytenoid chondritis, epligottic entrapment, ventral displacement of
the corniculate processes, laryngeal mass, epiglottic ulceration, sub-
epiglottic cyst, subepiglottic tissue, arytenoid granuloma and rostral
displacement of the palatopharyngeal arch.3,30 The total number of
DUAO diagnosed during the examination of each horse was
grouped into four groups for statistical analysis (from 0 to ≥ 3).
This was because of the small number of horses that were diag-
nosed with > 3 obstructions.
Fisher’s exact tests were used to detect associations between each of
age/sex/resting laryngeal grade/DUAO found. Multinomial logistic
regression was used to determine association between male and
female sex with relation to resting laryngeal grade. When appropri-
ate, Spearman’s rank correlation coefficient was used to determine
the direction of the associations. Statistical significance was consid-
ered as P < 0.05.
Results
Study population
Of 411 OGE examinations performed from February 2010 to March
2014, 100 video examinations were excluded according to the inclu-
sion criteria; the remaining 311 examinations were analysed:
210 (67.5%) males (colts and geldings) and 101 (32.5%) females,
aged 1–8 years (median, 3).
Presence of DUAO
No DUAO were found in 19.9% (62/311) of the horses (Table 1).
The remaining 80.1% (249/311) had ≥ 1 DUAO: 28.9% (72/311) had
1, 57.0% (142/311) had 2 and 14.1% (35/311) had ≥ 3 (max. 5).
Older horses were more likely to be diagnosed as ‘Other’ than
younger horses: 7.9% (7/89) horses ≤ 2 years versus 18.5% (17/92)
horses ≥ 4 years (P = 0.03). No other obstruction category was sig-
nificantly associated with age.
Male horses were more likely to be diagnosed with ACC or VFC
than female horses (P < 0.01): ACC was present in 58.6% (123/210)
of males and 37.6% (38/101) of females; right-sided and biaxial VFC
was present in 52.9% (111/210) of males and 34.7% (35/101) of
females. Female horses were more likely to have DDSP: 24.8%
(25/101) versus 11.4% (24/210) males (P < 0.01).
ACC was the most common single DUAO, occurring in 22.2%
(16/72) of horses. ACC + VFC was the most frequent combination
in horses with 2 obstructions, occurring in 70.4% (100/142) of
horses. ACC + VFC + MDAF was the most common combination
for horses with ≥ 3 obstructions, occurring in 65.7% (23/35) of
horses.
Australian Veterinary Journal Volume 95 No 9, September 2017 339
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Table 1. Frequency of horse signalment and dynamic upper airway
obstructions (DUAO) within each cohort of resting laryngeal grade from
the study population of Australian Thoroughbred racehorses
Resting grade
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Horses with dynamic ACC
Resting arytenoid grades 3–5 were associated with a greater likeli-
hood of being grade C (P < 0.01) during exercise. Exercising grades
A and B were observed in 100% (65/65) of resting grade 1 horses,
99% (81/82) of horses with grade 2, 91% (30/33) of horses with grade

1 2 3 4 5 3 and 33% (40/121) of horses with grade 4. Exercising grade B was

observed in 20% (2/10) of horses with resting grade 5 (Table 1).
Total 65 82 33 121 10 Exercising grade C was observed in 1% (1/82) of horses with resting
Sex laryngeal grade 2, 9.1% (3/33) of horses with grade 3, 68.6% (81/121)
Male 39 45 25 92 9 of horses with grade 4 and 80% (8/10) of horses with grade
Female 26 37 8 29 1 5 (Table 1).
Age (years)
≤2 18 22 15 30 4 Presence of an abnormal exercising respiratory noise
3 31 30 7 57 5 An abnormal respiratory noise was reported before the OGE in
≥4 16 30 11 34 1 217 of the 311 horses (70.0% of the total study population); 80%
≥ 1 DUAO 34 59 27 119 10 (199/249) of horses with ≥ 1 DUAO and between 75% and 88% of
Cause of DUAO each DUAO group produced an abnormal exercising respiratory
ACC 2 12 19 118 10 noise (Table 2). An abnormal exercising respiratory noise was noted
DDSP 17 25 3 4 0 in 29.0% (18/62) of horses with no observable DUAO. Significant
VFC 4 19 11 102 10 associations were found between an abnormal exercising respiratory
noise being present during exercise and the horse having ≥ 1 DUAO,
MDAF 12 17 9 24 2
ACC, VFC (P < 0.01) and DDSP (P = 0.03) (Table 2).
NPC 6 5 1 0 0
Other 8 8 5 11 2
ACCa 2 12 19 118 10 Discussion
B 2 11 16 37 2
C 0 1 3 81 8 Our report describes the OGE findings from a large population of
Australian TB racehorses. We reviewed the findings from horses
Data are frequency of horses. Horses may have ≥1 DUAO, therefore undergoing a standardised OGE with a focus on the incidence of dif-
total DUAOs exceed the total population. ferent forms of DUAO and resting endoscopic examination findings.
a
B, between full abduction and resting position; C, abduction is equal The correlations between OGE and resting laryngeal endoscopy
to or less than resting. examination were explored in an effort to provide useful information
ACC, arytenoid cartilage collapse; DDSP, dorsal displacement of the
soft palate; MDAF, medial deviation of the aryepiglottic fold; NPC,
for veterinarians performing an examination without access to OGE.
nasopharyngeal collapse; VFC, vocal fold collapse.
The population of this study comprised both primary and referral
OGE cases, presenting for poor performance and/or abnormal respi-
Laryngeal function at rest ratory noise. Prior to OGE, the horses included underwent a brief
Grade 4 arytenoid abduction was found in 39.0% (121/311) of the lameness examination and resting upper airway endoscopy. Males
total study population (Table 1). This grading was also the most were overrepresented in this study population, with approximately
common for each of the three age groups and in 43.8% (92/210) of 70% over the three age groups being male. This differs from the
the total males. Conversely, grade 2 was the most common grading annual registration of Australian racehorses, which between 2003
for females, affecting 37.0% (37/101) of the total females. Resting and 2012 was consistently close to 50% for males and females each
arytenoid grades of 3–5 were associated with ACC, VFC, ≥ 1 DUAO year.31 The over-representation of males has been previously
(P < 0.01) and being male (P = 0.05). Resting arytenoid grades of reported in OGE and HSTE studies of poor performance in similar
1–2 were associated with DDSP (P < 0.01), NPC (P = 0.01) and populations, likely indicating an anatomical reason and the preva-
being female (P = 0.05). lence of recurrent laryngeal neuropathy.2,6,15,19,29,32 In our population

Table 2. Thoroughbred racehorses with an abnormal exercising respiratory noise and dynamic upper airway obstruction (DUAO) present during
overground endoscopy of the study population between February 2010 and March 2014

≥ 1 DUAO No DUAO ACC DDSP VFC MDAF NPC Other

No noise 50 44 31 6 25 16 2 7
Noise 199 (P < 0.01) 18 130 (P < 0.01) 43 (P < 0.03) 121 (P < 0.01) 48 10 27

Data are number of horses.

ACC, arytenoid cartilage collapse; DDSP, dorsal displacement of the soft palate; MDAF, medial deviation of the aryepiglottic fold; NPC, nasopha-
ryngeal collapse; VFC, vocal fold collapse.

340 Australian Veterinary Journal Volume 95 No 9, September 2017 © 2017 Australian Veterinary Association

of horses, comparatively more females were found to have DDSP
compared with males.
From the total study population, 80% of horses were found to have a
DUAO when examined. It is possible that an additional examina-
tion, potentially when working with another horse over greater dis-
tances or an HSTE may have revealed a diagnosis of DUAO in some
of the horses in which no DUAO was identified. In none of the cases
was the lack of diagnosis related to poor image quality. Prior reports
of equine poor performance evaluations identifying DUAO have
reported a lower incidence than in this study.33,34 This is possibly
related to this particular study population, being comprised of TBs
performing maximally, thus accentuating the potential for DUAO to
be identified.
During their HSTE evaluation of a UK population of TB racehorses,
Lane et al.3 found a similar proportion of horses experiencing
DUAO as in the current study. The presence of complex (> 1)
DUAO in that report (30%) was less than the 71% that we found,
which may indicate that the OGE examination gives a more accurate
picture of the complexity of the DUAO present. They found DDSP
to be the most common (50%) HSTE diagnosis, illustrating the dif-
ferences between OGE and HSTE. Relatively few (6%) of their study
population had a resting grade 4 or 5; potentially, referring veterinar-
ians were less likely to further investigate these ‘straightforward’
cases of recurrent laryngeal neuropathy. In contrast, we found ACC
to be the most common OGE diagnosis (64%), greater than was
diagnosed by Lane et al. (24%).3 Palatal instability, described as
dorsoventral ‘billowing’ of the caudal border of the soft palate, was
seen less in our study (< 2.5%) than previously reported.3,30 This is
likely because of PI being linked to DDSP, which we also reported
less of, and the inherent subjectivity of diagnosing and describing
PI.30 Our study comprised more horses with resting grade 4 or
5 (42%) undergoing OGE to ascertain the extent of, and further,
DUAO. Because of this higher prevalence of grade 4 or 5 horses,
more cases of dynamic ACC occurred and less of DDSP. Importantly
from a clinical standpoint, these higher grade horses displayed multi-
ple forms of DUAO that were not discernible at rest and, based on
the more detailed understanding of the complex forms of collapse,
allowed for more specific intervention. Also, it allowed for fair com-
parison of surgical success in a more complete manner than if OGE
had not been performed prior to a grade 4 or 5 horse having surgery.
This study highlights the usefulness of dynamic endoscopy even in
‘straightforward’ cases, as there is often multiple forms of DUAO
occurring, which will be missed without these examinations.
Of the DUAO categories investigated, only ‘Other’ was associated
with age, becoming more likely with older horses. The ‘Other’ cate-
gory comprises uncommon diagnoses that may be acquired/further
develop as the horse ages. ACC caused by recurrent laryngeal neu-
ropathy, a degenerative disease, did not significantly increase with
age as may be expected. The age range of the current study popula-
tion may be too small to allow enough detection of further ACC pro-
gression.35 The most common obstruction was ACC and often found
to represent one part of a complex, dynamic obstructive disorder
involving VFC and MDAF. Although not statistically significant,
there was a trend for a reduction in the diagnosis of DDSP in older
horses. Younger horses, with greater pharyngitis/lymphoid
© 2017 Australian Veterinary Association
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hyperplasia leading to chronic generalised pharyngeal inflammation,
may be a potential reason for the greater incidence of DDSP in this
age group. We did not grade or analyse the degree of lymphoid
hyperplasia in this study.
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There was a positive correlation between resting laryngeal grade and
dynamic ACC. This study aimed to investigate the ‘grey zone’ invol-
ving horses that have significant asymmetry at exercise but full
abduction (grade 3) at rest, as well as those that cannot fully abduct
(grade 4) at rest. Of the horses with resting grade 3, the majority
(91%) had full or partial abduction at exercise. The remaining (9%)
horses had abduction equal or less than when resting. As expected,
grade 4 horses had a large decrease in ability to fully or partially
abduct (33%). In a surprisingly high percentage (20%) of resting
complete collapse (grade 5) cases, there was a degree of exercising
abduction during OGE. However, this observation is drawn from
only a small number of horses (n = 10), as few grade 5 horses under-
went OGE, likely based on the assumption that none would have
any abduction ability. Retrospectively, this may have been occasion-
ally incorrect. From the findings of this study and based on the level
of their exercising abduction, up to 33% of grade 4 horses and 20%
of grade 5 horses may not improve their exercising abduction level
after prosthetic laryngoplasty. In fact, as shown by Leutton et al.,
performing surgery on these horses may increase their level of
DUAO, as well as potentially encountering the established surgical
risks and side effects of this surgery.25,36 This reinforces the value of
OGE in allowing for appropriate surgical case selection and will
likely ensure improved success rates associated with a complete pre-
operative diagnosis. However, OGE interpretation must allow for the
sometimes submaximal nature of the examination and the often pro-
gressive nature of recurrent laryngeal neuropathy.35
The presence of an abnormal respiratory noise was an accurate indi-
cator of DUAO in general, but not for any specific form; 80% of
horses making a noise were found to have ≥ 1 DUAO, but 29% of
horses without a noise still had a form of DUAO. A history of mak-
ing a noise was found between 75% and 88% for each DUAO group.
These findings reinforce the need for trainer/rider observations of
abnormal exercising respiratory noise as part of a thorough upper
airway investigation.
Conclusion
This study examined a large population of Australian TB racehorses
that underwent an OGE. Complex DUAO, as well as abnormal exer-
cising respiratory noise during OGE, was found to be common, with
the age and sex of the horse influencing the findings. Important dif-
ferences were found between this OGE study and previous HSTE
studies, which may have a bearing on surgical case selection. Corre-
lations between resting and exercising laryngeal function are valua-
ble, particularly when OGE is not available to clinicians.
Acknowledgments
We thank the veterinarians, owners and trainers who made this
study possible. JA Davison, JM Lumsden and BJ Ahern contributed
to the study design, data collection, data analysis, interpretation and
Australian Veterinary Journal Volume 95 No 9, September 2017 341
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manuscript preparation. RC Boston contributed to data analysis and
interpretation. I Bayliss, C Elliott, J Leutton, V Locke, N Pagan, R
Perez, R Salz and S Sommerauer contributed to data collection.
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