Adenoidectomy

Adenoidectomy, often performed with or without grommet insertion, may be done alone or in combination with tonsillectomy. This procedure is among the most frequently performed surgeries in children. When combined with tonsillectomy, the adenoids are removed first, and the nasopharynx is packed before starting the tonsillectomy. Despite its disadvantages, such as unpredictable bleeding, poor access to choanal adenoids causing recurrence, and potential injury to the eustachian tube opening, blind curettage remains the most commonly used adenoidectomy method.

Other Techniques for Adenoidectomy include:

1. Endoscopic Adenoidectomy
2. Suction Diathermy Adenoidectomy
3. Coblation Adenoidectomy
4. Microdebrider Adenoidectomy
5. KTP Laser Adenoidectomy

Suction diathermy minimizes blood loss and postoperative bleeding. Coblation and microdebrider methods are costly, while KTP laser poses a high risk of nasopharyngeal stenosis.

Preoperative Assessment:

1. Investigations for surgical fitness: Hemogram, urine analysis (routine and microscopic), blood sugar (fasting), blood urea/creatinine, chest X-ray, ECG.
2. Coagulation Profile: Prothrombin time, partial thromboplastin time, bleeding time, and platelet count.
3. X-ray of the Nasopharynx (Lateral View with Open Mouth): To assess adenoid size and nasopharyngeal air space compromise.
4. Nasal Endoscopy: Useful for assessing adenoid size in cooperative children.
5. Children with Down Syndrome: Assess for potential atlantoaxial instability and cardiac abnormalities.

Indications for Adenoidectomy:

1. Adenoid Hypertrophy: Causing snoring, mouth breathing, obstructive sleep apnea syndrome, craniofacial growth abnormalities, or speech abnormalities (e.g., rhinolalia clausa).
2. Chronic Otitis Media with Effusion: Due to anatomical obstruction of the eustachian tube.
3. Recurrent Acute Otitis Media: Associated with adenoiditis or adenoid hyperplasia.
4. Dental Malocclusion: Adenoidectomy does not correct dental abnormalities but prevents recurrence after orthodontic treatment.
5. Recurrent Rhinosinusitis

Contraindications for Adenoidectomy:

1. Cleft Palate or Submucous Palate: Removal of adenoids causes velopharyngeal insufficiency.
2. Haemorrhagic Diathesis
3. Acute Infection of the Upper Respiratory Tract

Position for Surgery:

Rose’s position: The patient lies supine with the head extended by placing a pillow under the shoulders, stabilized with a rubber ring. Hyperextension should be avoided. The procedure is performed under general anaesthesia.

 Steps of the Operation:

1. Mouth Opening and Gag Insertion: The mouth is opened, and a Boyle-Davis mouth gag is inserted and suspended with Draffin’s bipods to stabilize the head. The soft palate is elevated with a curved tongue depressor and by digital palpation, pushing the adenoids medially.
2. Throat Pack Insertion: To prevent blood and secretions from entering the oesophagus and aspiration of laryngeal clots, as well as to prevent leakage of air, oxygen, and anaesthetic agents.
3. Adenoid Curette Insertion: Using the appropriate size of “St. Clair Thomson’s adenoid curette with guard,” the curette is introduced into the nasopharynx to engage the adenoids.
4. Adenoid Removal: With gentle sweeping movements, the adenoids are shaved off. Smaller curettes are used for lateral masses, and any remaining lymphoid tissue is removed with punch forceps. Care is taken to avoid injury to the pharyngeal ends of the eustachian tubes.
5. Haemostasis: Achieved by packing the area for some time. Persistent bleeders are electrocoagulated under vision. If bleeding persists, a postnasal pack is left for 24 hours.

Postoperative Care:

1. Monitoring: Look for bleeding from the nose and mouth, and observe vital signs (pulse, respiration, blood pressure). Keep the patient in a coma position until fully recovered from anaesthesia.
2. Diet: Allow liquids like cold milk or ice cream when the patient is fully recovered. Sucking on ice cubes can relieve pain. Gradually build the diet from soft to solid food, encouraging plenty of fluids.
3. Gargles: Use betadine or saltwater gargles three to four times a day. A mouthwash with plain water after every feed helps keep the mouth clean.
4. Medications: Pain can be relieved with analgesics like paracetamol. A suitable antibiotic can be given orally or by injection for a week.
5. Discharge: Patients are usually sent home 24 hours after the operation unless complications arise. Normal activities can be resumed within two weeks.

Complications:

1. Haemorrhage: Can occur immediately post-op to the first 24 hours (reactionary haemorrhage) or after 24 hours (secondary haemorrhage) due to bleeding from an aberrant ascending pharyngeal artery. Unusual bleeding may indicate a clotting or coagulation defect. Nose and mouth may be full of blood or the only indication may be vomitus of dark-coloured blood which the patient had been swallowing gradually in the postoperative period. A rising pulse rate is another indicator. Shift the patient immediately to the operation theatre and postnasal packing should be done under general anaesthesia. Postnasal packing left in situ for 4 hours post-haemorrhage is as effective as packs left for 24 hours.
2. Injury to the Eustachian Tube Opening
3. Injury to Pharyngeal Musculature and Vertebrae: Due to hyperextension of the neck and undue pressure from the curette. Extra care is needed for Down syndrome patients, who may have atlantoaxial instability.
4. Grisel Syndrome: Rare, occurs due to spasm of paraspinal muscles or atlantoaxial dislocation, often from excessive diathermy use during surgery.
5. Velopharyngeal Insufficiency: Check for submucous cleft palate before adenoid removal.
6. Nasopharyngeal Stenosis: Due to scarring.
7. Recurrence: Due to regrowth of adenoid tissue left behind.
8. Dental Injury: Can occur accidentally from gag or support slippage.
9. Nasopharyngeal Blood Clot: Blood may pool and clot in the nasopharynx during the procedure and should be suctioned out before removing the gag to prevent potentially fatal acute airway obstruction.

——– End of the chapter ——–

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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