Obstructive Adenoid Tissue
An Indication for Powered-Shaver Adenoidectomy
Thomas Havas, FRACS;
David Lowinger, FRACS
Arch Otolaryngol Head Neck Surg. 2002;128:789-791.
ABSTRACT
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Objectives To quantify the incidence of intranasal extension of adenoid tissue
and residual adenoidal obstruction of the posterior choanae following traditional
curette adenoidectomy to determine the efficiency of adenoid curettage and
the usefulness of intraoperative endoscopic examination and powered-shaver
adenoidectomy in achieving better postnasal patency.
Design Prospective intraoperative endoscopic evaluation of the posterior choanae
and nasopharynx of a case series of 130 patients before and after curette
and powered-shaver adenoidectomy.
Setting Tertiary referral center.
Patients One hundred thirty consecutive pediatric patients with obstructive adenoidal
hypertrophy undergoing adenoidectomy.
Main Outcome Measures The degree of residual postnasal obstruction due to adenoid tissue was
assessed endoscopically (grades 0-3) after curette and adjuvant powered-shaver
adenoidectomy. The presence of intranasal adenoid tissue was also recorded.
Results Following traditional curette adenoidectomy, 51 (39%) of 130 patients
had residual obstructive adenoid with 42 patients (32%) having occlusive intranasal
adenoid tissue. Having determined the presence of remaining obstructive tissue
with intraoperative nasal endoscopy in these 51 patients, complete airway
patency was achieved with powered-shaver adenoidectomy.
Conclusion The presence of intranasal extension of adenoids obstructing the posterior
choanae is common in children with adenoid hypertrophy. Traditional adenoidectomy
is ineffective in removing this tissue and may also leave obstructive tissue
high in the nasopharynx. Intraoperative nasal endoscopy allows assessment
of the completeness of surgery. Powered-shaver adenoidectomy enables complete
removal of obstructive adenoid tissue thereby ensuring postnasal patency.
INTRODUCTION
ADENOIDS, which are nasopharyngeal lymphoid tissue forming part of the
Waldeyer ring, were initially described in 1868 by Meyer.1
Present from early gestation, adenoid growth continues until about 6 years
of age, after which atrophy occurs. Adenoidal hypertrophy during childhood
may both fill the nasopharynx and extend through the posterior choanae into
the nose, resulting in nasal airway stenosis, impeding airflow. There is a
significant relationship between the endoscopically determined size of obstructive
adenoid tissue and symptomatic nasal obstruction in children.2
Sequelae include mouth breathing and rhinorrhea, sleep-disordered breathing,
speech anomalies, feeding difficulties, chronic sinusitis, and craniofacial
growth anomalies.
These clinical manifestations may be readily remedied with removal of
obstructive hypertrophic adenoid tissue to restore airway patency. The widely
used conventional curette adenoidectomy was first described in 1885.1 Dissatisfaction with this technique has prompted the
use of other methods, including powered-shaver adenoidectomy.3
While there is a perception that shaver adenoidectomy is more effective
in clearing adenoid tissue compared with curettage, this has yet to be objectively
assessed. We undertook this study to evaluate the adequacy of removal of obstructive
adenoid with the traditional curette technique to determine whether endoscopically
guided powered-shaver adenoidectomy would attain better clearance.
PATIENTS AND METHODS
PATIENTS
One hundred thirty consecutive paediatric patients with obstructive
adenoid hypertrophy undergoing adenoidectomy were included in this study.
All patients were assessed preoperatively with transnasal endoscopy and determined
to have obstructive adenoid hypertrophy (grades 2 and 3). Only patients in
whom a partial adenoidectomy was intentionally performed, such as those with
palatal dysfunction, were excluded. All adenoidectomies were performed by
or under the supervision of the senior author (T.H.).
The following grading system was used to standardize the endoscopic
assessment of the degree of airway obstruction due to adenoid tissue:
"Significant obstruction" was determined to be stenosis of the posterior
choanae of 60% or more (grades 2 and 3) based on clinical experience and nasal
airflow models.4
Operations were performed under general anesthesia. When tonsillectomy
or myringotomy were performed and tubes were placed during the same anesthetic,
these were completed prior to adenoidectomy.
METHODS
In each case, the patient was anesthetized and an oral endotracheal
tube or laryngeal mask placed. The child was placed supine in the Rose position
with a small pillow under the shoulders to allow slight neck extension and
was covered with sterile drapes.
Using a 0° 2.7-mm rigid fiberoptic telescope (Storz, Tuttlingen,
Germany), obstructive adenoidal hypertrophy was confirmed. With a Boyle-Davis
mouth gag splinting the mouth open, the palate and uvula were inspected and
palpated to exclude a soft palate cleft. An appropriate-sized unguarded adenoid
curette was then used to remove adenoid tissue. The surgeon was allowed to
palpate the adenoid bed and repeat the curettage until satisfied with completeness
of removal. The adenoid bed was then suctioned and a nasopharyngeal sponge
placed for a few minutes for hemostasis. The sponge was then removed, a Y-suction
catheter passed through the nose to ensure removal of any loose clot or tissue,
and the nasopharynx inspected to ensure cessation of bleeding.
The nose and nasopharynx were then inspected again with the 0° 2.7-mm
rigid telescope with a video attachment allowing assessment by both the surgeon
and an independent colleague (ear, nose, and throat [ENT] consultant or senior
ENT registrar). The presence of persisting viable intranasal adenoid and/or
residual obstructive nasopharyngeal adenoid tissue was recorded for each side
of the nose. The degree of obstruction at the posterior choanae was standardized
according to the numerical grading scale (grades 1-3).
Patients with a grade 2 or 3 remaining stenosis then underwent completion
of the adenoidectomy using a powered shaver.
TECHNIQUE
A transnasal powered-shaver adenoidectomy technique guided by transnasal
videoendoscopy was used. The shaver used is the 3-in-1 XPS Xomed Power System
with the lightweight magnum-scaled handpiece and a 2.9-mm Tricut blade with
straight-through suction irrigation (Medtronic Xomed Surgical Products, Jacksonville,
Fla).
The theater setup and positioning is as for a standard functional endoscopic
sinus surgery: First, oxymetazoline hydrochloride–soaked 1-inch pledgets
are placed into each side of the nose for a few minutes to vasoconstrict and
enhance access. A sponge soaked in oxymetazoline is placed, perorally, into
the nasopharynx and left there until the procedure is completed. This assists
hemostasis and prevents occult blood loss into the oropharynx. Using the 0°
2.7-mm rigid telescope (4 mm in older children), the posterior choanae and
nasopharynx are assessed. Under endoscopic vision the shaver cannula is passed
into the nose with the suction switched off to allow passage through to the
adenoid without traumatizing the turbinates or septum. The suction is then
turned on and obstructive tissue removed under constant endoscopic vision
with care not to lacerate the torus tubarius. The cutting and aspirating action
of the shaver removes both adenoid tissue and blood, providing a clear view.
Working from proximal to distal, intranasal adenoid and hypertrophic
nasopharyngeal adenoid are removed until the surgeon is satisfied with the
clearance. Pledgets soaked in either hydrogen peroxide or oxymetazoline are
then directly applied, under endoscopic vision, to any bleeding point until
hemostasis is established. The nasopharyngeal sponge is removed and routine
postoperative and discharge protocol followed.
Owing to the study protocol, there was an obvious increase in operative
time when both curette and shaver techniques were used. However, we were certain
that we had achieved complete clearance of the nasal airway in every patient.
There was no primary or secondary bleeding in any case, nor any delay in discharge
from the hospital.
RESULTS
One hundred thirty consecutive patients requiring adenoidectomy were
included in this study. Seventy-nine were male and 51 female, with ages ranging
from 10 months to 14.1 years.
The indication for adenoidectomy was adenoidal hypertrophy causing nasal
obstruction in all cases. In 40 cases the indication for surgery was obstruction
alone. Twenty-three patients had associated persistent sinusitis and 67 had
associated recurrent otitis media.
Following traditional curette adenoidectomy, each of the 130 patients
was assessed endoscopically. Overall, 51 patients (39%) had remaining obstructive
adenoid (grade 2 or 3).
Forty-two (32.3%) of the 130 patients had residual intranasal adenoid
tissue still occluding the posterior choanae after curette adenoidectomy (Table 1). Nine other patients had significant
residual obstructing adenoid tissue remaining high in the nasopharynx (grade
2 or 3). These 51 patients had further adenoid removal with the small joint
shaver, achieving complete postnasal patency (grades 0 and 1) (Table 2).
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Table 1. Intranasal Adenoid Findings
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Table 2. Airway Patency Assessment*
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COMMENT
The objective of adenoidectomy is to remove the hypertrophic adenoid
tissue that causes nasal airway stenosis leading to pathological restriction
of nasal airflow.
Dissatisfaction with the traditional curette adenoidectomy in adequately
and safely achieving this clearance has led to the development of alternative
techniques that have been made possible by developments in fiberoptics and
endoscopic instrumentation.3, 5-6
The main disadvantage of curettage is that it is a relatively "blind"
technique that may lacerate the choanae and torus tubarius, gauge the nasopharyngeal
mucosa, or skim the adenoid bulk, leaving behind obstructing tissue, particularly
at the eustachian tube orifices, high in the nasopharynx, and at intranasal
protrusions.7 The use of an adenoid punch or
avulsion with grasping forceps, under endoscopic vision, may be similarly
traumatic.
Insulated suction diathermy adenoid ablation has been a popular alternative.8
While suction diathermy ablation usually minimizes blood loss, it may
not address intranasal adenoid tissue, is slow, and carries the potential
risks of cicatrization and collateral burns as does the use of the carbon
dioxide laser, which also requires full laser precautions.
The powered-shaver method has been applied in a number of ways. It may
be the primary technique, used as an adjunct to curettage, or coupled with
other methods.
Route of visualization and access to the adenoid may be transoral, transnasal,
or a combination. The transoral procedure is performed using an angled mirror
and specially developed 40° curved blades with the cutting window on the
circumference. Transnasal direct endoscopic vision combined with the powered
shaver allows precise removal of obstructive tissue while preserving mucosa
and normal nasopharyngeal structures. Intranasal adenoid tissue and tissue
high in the nasopharynx may be readily identified and removed. The oscillating
cutting action of the shaver blade minimizes bleeding and the continuous suction
maintains a clear view enhancing safety. In cases that require partial adenoidectomy
the precision and safety of this technique are of particular advantage. Further,
by operating through the nose there is no need for hyperextension of the neck
in patients, such as those with Down syndrome, who may have congenital instability
of the cervical spine. By operating with the video attachment on the telescope,
the theater staff may be more involved in the operation, and trainee teaching
is facilitated.
Restrictions of powered-shaver adenoidectomy to date have largely been
due to problems inherent in adapting an orthopedic instrument to nasal surgery.
These included heavy handpieces with blade width and angles unsuitable to
a crowded nose, leading to damage to normal nasal structures and poor maneuverability
in the nasopharynx.6 We found that even in
small children, transnasal surgery using the lightweight magnum handpiece
and 2.9-mm blade with a triangulated window kept clear with continuous suction
irrigation, combined with a 2.7-mm telescope, enabled a highly controlled
adenoid clearance. Useful supplementary techniques were the transoral placement
of an oxymetazoline-soaked sponge low in the nasopharynx before shaving and
ensuring that the shaver suction was off during passage of the blade through
the nose.
Today there is a wide choice of methods available to perform this common
operation. While it is tempting to presume that applying new technology is
preferable to "old-fashioned" techniques, the benefits ought be critically
quantified and assessed before accepting a change. This study has demonstrated
that in up to 39% of children with clinically significant adenoid hypertrophy,
curette adenoidectomy does not achieve adequate removal of obstructive adenoid
tissue, especially when there is intranasal extension of adenoid or a bulky
mass of adenoid high in the nasopharynx. In such cases the use of powered-shaver
technique enables better clearance of obstructive adenoid.
We therefore recommend that endoscopic visualization during adenoidectomy
is worthwhile and that in some cases the powered-shaver adenoidectomy provides
more reliable restoration of nasal patency.
AUTHOR INFORMATION
Accepted for publication December 5, 2001.
Corresponding author and reprints: Prof Thomas Havas, FRACS, Suite
506, 253 Oxford St, Bondi Junction, Sydney, New South Wales 2022, Australia.
From the Department of Otolaryngology, Sydney Children's Hospital,
Sydney, Australia.
REFERENCES
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1. Thornval A. Wilhelm Meyer and the adenoids. Arch Otolaryngol. 1969;90:383-386.
PUBMED
2. Wang DY, Clement PA, Kaufman L, Derde MP. Chronic nasal obstruction in children: a fiberoptic study. Rhinology. 1995;33:4-6.
PUBMED
3. Parsons DS. Rhinologic uses of powered instrumentation in children beyond sinus
surgery. Otolaryngol Clin North Am. 1996;29:105-114.
PUBMED
4. Di Martino E, Mlynski G, Mlynski B. Effect of adenoid hyperplasia on nasal airflow [in German]. Laryngorhinootologie. 1998;77:272-274.
PUBMED
5. Huang HM, Chao MC, Chen YL, Hsiao HR. A combined method of conventional and endoscopic adenoidectomy. Laryngoscope. 1998;108:1104-1106.
PUBMED
6. Yanagisawa E, Weaver EM. Endoscopic adenoidectomy with the microdebrider. Ear Nose Throat J. 1997;76:72-74.
PUBMED
7. Koltai PJ, Kalathia AS, Stanislaw P, Heras HA. Power-assisted adenoidectomy. Arch Otolaryngol Head Neck Surg. 1997;123:685-688.
ABSTRACT
8. Wright ED, Manoukian JJ, Shapiro RS. Ablative adenoidectomy: a new technique using simultaneous liquifaction/aspiration. J Otolaryngol. 1997;26:36-43.
PUBMED
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