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Powered Partial Adenoidectomy
Nicole Murray, MD;
Philip Fitzpatrick, MD;
J. Lindhe Guarisco, MD
Arch Otolaryngol Head Neck Surg. 2002;128:792-796.
ABSTRACT
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Objective To confirm our clinical impression that the powered microdebrider is
superior to curettes for performing partial adenoidectomy (removal of the
superior one half to three fourths of the adenoid pad).
Design Observational study of 100 children undergoing partial adenoidectomy
with the powered microdebrider compared with 40 children undergoing conventional
partial adenoidectomy with curettes.
Setting Private and public tertiary care centers.
Patients All patients younger than 20 years undergoing partial adenoidectomy
at the respective institutions during the study period.
Interventions Partial adenoidectomy as indicated for chronic otitis media, airway
obstruction, or chronic or recurrent tonsillitis with either the powered microdebrider
or curettes.
Main Outcomes Measures Operative time (with specific quantification of the time required for
tissue removal and hemostasis), blood loss, complications, and subjective
ease of use.
Results Operative time was 59% shorter for the microdebrider group (mean, 3
minutes 22 seconds; range, 1 minute 6 seconds to 12 minutes 45 seconds) than
for the conventional group (mean, 8 minutes 8 seconds; range, 1 minute 2 seconds
to 22 minutes 0 seconds) (P<.001). Blood loss
was comparable for both groups (powered group: mean, 2.0 mL/kg; range, 0.4
to 9.4 mL/kg; conventional group: mean, 2.0 mL/kg; range, 0.3 to 6.7 mL/kg; P=.34). There were no intraoperative or postoperative complications
in either group. Surgeon satisfaction with the microdebrider was high.
Conclusions The powered microdebrider for partial adenoidectomy is quicker and is
not associated with blood loss or complications above that of conventional
partial adenoidectomy. The degree of control afforded by the microdebrider
technique is of utmost value in preventing complications such as velopharyngeal
insufficiency, and this is now our procedure of choice.
INTRODUCTION
ADENOIDECTOMY, whether performed with tonsillectomy, with myringotomy,
or alone, is the second most common major surgical procedure performed on
children today.1 Complications such as velopharyngeal
insufficiency, eustachian tube stenosis, and nasopharyngeal stenosis are uncommon
yet difficult to repair once encountered. Prevention is therefore of utmost
importance. To prevent velopharyngeal insufficiency, many otolaryngologists
routinely perform a partial adenoidectomy. This technique involves the removal
of the superior 50% to 80% of the adenoid pad, which leaves an inferior tissue
remnant undisturbed to ensure adequate velopharyngeal closure (Figure 1). Precise operative technique is critical for the successful
performance of partial adenoidectomy, as care must be taken not to remove
the entire adenoid pad. The powered microdebrider (Medtronic Xomed, Jacksonville,
Fla) is ideally suited for this purpose. It consists of an outer windowed
sheath surrounding an inner rotating hollow blade that is connected to standard
in-line continuous suction (Figure 2).
The surgeon directs the window toward the desired tissue, which is drawn in
by the vacuum, and the rotating blade then shaves the tissue. The amount of
tissue removed is thus easily controlled. The objective of this study was
to confirm the clinical impression that partial adenoidectomy with the powered
microdebrider is superior to that with curettes.
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Figure 1. Line drawing showing partial adenoidectomy
with the microdebrider. Note the amount of adenoid tissue left inferiorly
to ensure adequate velopharyngeal closure.
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Figure 2. A, Photograph of the assembled
microdebrider. B, Detail of cutting surface.
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PATIENTS AND METHODS
Children and young adults who underwent partial adenoidectomy, as indicated
for chronic otitis media, nasal obstruction, or chronic or recurrent tonsillitis,
at 3 public and private tertiary care centers during the study period from
October 1997 through July 1998 were studied prospectively in this observational
series. All patients younger than 20 years were included; 1 patient with a
preoperative coagulopathy that required intense preoperative preparation with
transfusion of clotting factors was excluded. One hundred patients underwent
partial adenoidectomy with the powered microdebrider and 40 underwent partial
adenoidectomy with curettes. The adenoidectomy technique (curettes vs the
microdebrider) was chosen by the attending surgeon. Procedures were performed
either by staff otolaryngologists (approximately 10% in each group) or by
experienced otolaryngology residents under supervision (approximately 90%
in each group). At least half of the procedures in each group were performed
by the same resident. As curettes at the public hospital were often dull,
new curettes were obtained for use in these patients to attempt to eliminate
bias resulting from this factor. One set of curettes was provided by Medtronic
Xomed; this study was otherwise not funded.
Partial adenoidectomy with either technique was performed under general
anesthesia with the patient in the Rose position. The oral cavity was carefully
examined for any signs of a palatal abnormality, and the amount of tissue
resected was tailored to each patient's individual anatomy. If a submucus
cleft was suspected or if the soft palate was short, up to 50% of the adenoid
pad was left undisturbed inferiorly. In the absence of abnormal anatomy, at
least 20% of the adenoid pad was left inferiorly to allow adequate velopharyngeal
closure. A red rubber catheter was placed for palate retraction, and a standard
defogged adenoid mirror was used for visualization. Partial adenoidectomy
with curettes was performed with freshly sharpened standard adenoid curettes
and completed with Ronis punch forceps if necessary. Partial adenoidectomy
with the microdebrider was performed with the Xomed RADenoid microresector
blade at 3000 rpm in oscillate mode without irrigation. After tissue removal
via either technique, electrocautery was used for hemostasis.
Data were recorded regarding patient age, weight, sex, indication for
adenoidectomy, and medical and surgical history. Intraoperative parameters
recorded were operative time, blood loss, submucus cleft stigmata, adenoid
size, palate length, and complications. Adenoid size was recorded, based on
the degree of nasopharyngeal obstruction noted on evaluation with the mirror
after the palate was retracted, as small to moderate (<50% obstruction),
large (50%-75% obstruction), or very large (>75% obstruction). The time in
minutes and seconds (minutes:seconds) was recorded on a watch with a second
hand for each patient for tissue removal, hemostasis, and total time. Time
began when the instrument touched the tissue and stopped when the procedure,
or portion thereof being recorded, was deemed complete by the surgeon. Precise
blood loss was calculated for the adenoidectomy portion of each procedure
by recording the exact amount of irrigation used and the exact volume of blood
and irrigation in the suction canister. We do not use in-line irrigation that
is available with the microdebrider for adenoidectomy, so this did not confound
our measurements of irrigation and blood loss. Charts were reviewed for postoperative
complications; patients who did not return for follow-up were contacted by
telephone and questioned regarding complications specifically including speech
or swallowing changes. Data were compiled and analyzed using a spreadsheet
program (Excel version 5.0; Microsoft, Redmond, Wash). Statistical significance
was evaluated with the Mann-Whitney test (SPSS for Windows Release 7.5.1 and
GraphPAD Instat Version 1.12a). Surgeons who had performed partial adenoidectomies
on both the curette group and the microdebrider group were questioned regarding
their level of satisfaction with the microdebrider and their future method
of choice for partial adenoidectomy.
RESULTS
Patient demographics, indications for adenoidectomy, and sizes of adenoid
pads are listed in Table 1. Results
are shown graphically in Figure 3
and Figure 4. Total operative time
was 08:08 for the curette group (range, 01:02-22:00) and 03:22 for the microdebrider
group (range, 01:06-12:45; P<.001). A significant
difference was noted in removal time, which was 03:22 for curettes (range,
00:12-14:00) vs 00:51 for the microdebrider (range, 00:07-05:10; P<.001) as well as in hemostasis time, which was 04:10 for curettes
(range, 00:50-10:47) vs 02:32 for the microdebrider (range, 00:52-09:00; P<.001). Blood loss was not statistically different
between groups, whether measured absolutely (48 mL [range, 5-375 mL] for curettes
vs 35 mL [range, 10-200 mL] for the microdebrider; P
= .66) or measured as blood loss per kilogram of body weight (2.0 mL/kg for
both curette and the microdebrider group [ranges, 0.3-6.7 and 0.4-9.4 mL/kg,
respectively]; P = .34). We also analyzed our results
by categorizing patients based on adenoid size. Figure 5 shows total operative time as stratified for the 3 size
groups. As expected, larger adenoids require more time for removal regardless
of technique. The difference in mean total operative time remained statistically
significant for each group at P<.008 for each
group. The amount of total operative time saved with the microdebrider is
shown in Table 2. On average,
the microdebrider saved 4 minutes 46 seconds or 59% of total operative time.
The amount of time saved was greatest for the largest adenoids, at 9 minutes
51 seconds or 65% of total operative time. When blood loss (per kilogram of
body weight) was stratified for adenoid size, no significant differences were
noted (Figure 6; P>.05 for all groups).
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Table 1. Demographics, Surgical Indications, and Size of Adenoid Pad
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Figure 3. Operative time for partial adenoidectomy
with the microdebrider or curettes (P<.001 for
all comparisons).
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Figure 4. Estimated blood loss (EBL) for
partial adenoidectomy with the microdebrider or curettes (P>.3 for both comparisons).
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Figure 5. Operative time as related to adenoid
size for partial adenoidectomy with the microdebrider or curettes (P<.008 for all comparisons).
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Table 2. Total Operative Time Saved With the Microdebrider Based on
Adenoid Size
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Figure 6. Blood loss as related to adenoid
size for partial adenoidectomy with the microdebrider or curettes (P>.05 for all comparisons).
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There were no intraoperative or postoperative complications in either
group. Surgeon satisfaction with the microdebrider was high as rated by the
3 surgeons (2 residents and 1 attending) who used both techniques in the study.
All 3 surgeons will continue to use the powered microdebrider for partial
adenoidectomy in the future.
COMMENT
Complications of adenoidectomy are fortunately rare. Postadenoidectomy
velopharyngeal insufficiency has been estimated to occur in 1 in 1500 to 1
in 10 000 cases.2-4
Nasopharyngeal stenosis and eustachian tube stenosis likely occur even less
frequently. All of these complications are difficult to handle if they occur;
treatments ranging in invasiveness from speech and swallowing therapy to multiple
operations are required. For these reasons, these complications are better
prevented than treated. Partial adenoidectomy is a technique preferred by
many otolaryngologists to avoid velopharyngeal insufficiency. An appropriately
sized remnant of inferior adenoid tissue is left in place to allow adequate
velopharyngeal closure. The amount of tissue left behind may be tailored to
each patient's anatomic needs: more tissue is left when the palate is short,
for example. This technique requires great control of tissue removal. Curettes
are designed for the removal of the entire adenoid pad; they are less useful
when the surgeon wishes to leave a specified amount of tissue inferiorly.
The microdebrider meets the demand for precision that partial adenoidectomy
requires. It has been proven ideal for handling tissue debridement during
endoscopic sinus surgery, where precision is required to avoid orbital or
intracranial entry or other complications.5
Expanded uses of the microdebrider in otolaryngology include removal of benign
and malignant nasal tumors, choanal atresia repair, laryngeal papilloma removal,
and adenoidectomy.6
Adenoidectomy (whether partial or complete) with the microdebrider is
approached in the same manner as for conventional adenoidectomy. The procedure
is visualized with a handheld mirror, and the view of the operative field
is identical to that of conventional adenoidectomy. Adenoidectomy with the
microdebrider using a transnasal endoscopic approach has been described7; we have found the addition of endoscopy to be unnecessary
in most cases.
Complete adenoidectomy with the microdebrider has been shown to be faster
than, and as safe as, adenoidectomy with curettes. One retrospective review
of complete adenoidectomy using curettes vs the microdebrider showed that
operative time was significantly faster with the microdebrider (11 vs 19 minutes)
and that blood loss, recovery time, and complications were comparable.8 A subsequent prospective randomized trial of complete
power-assisted adenoidectomy compared with curette adenoidectomy showed that
again operative time was significantly faster with the microdebrider (613
seconds, or 10 minutes 13 seconds, vs 734 seconds, or 12 minutes 14 seconds)
and that blood loss was significantly less with the microdebrider (15 vs 20
mL).9 Our results are in agreement with those
of these studies. Our operative times are significantly shorter; this is likely
due to the different methods of timing the procedure. Where we recorded start
and stop time when the instrument touched and left the tissue, prior studies
used either operative records or started and stopped recording when the mouth
gag went in and out of the mouth. We showed that for partial adenoidectomy,
the use of the microdebrider resulted in a statistically significant reduction
of 59% in overall operative time. It was interesting to note that the reduction
in operative time was not simply due to quicker tissue removal; hemostasis
time was quicker with the microdebrider. Hemostasis was achieved in the same
manner in both groups, perhaps reflecting a greater ability to remove all
adenoid tissue down to a less vascular fascial plane with the microdebrider.
This is logical due to the suction/shaving action of the microdebrider, which
draws loose tissue into the window, as opposed to the pushing/cutting action
of the curette blade, which may leave bleeding adenoid tissue behind. More
complete tissue removal allows more rapid hemostasis with electrocautery.
This difference in hemostasis time was not reflected by a statistically significant
reduction in blood loss for the microdebrider group in our study, however.
Stanislaw et al9 did show that blood loss was
less in the microdebrider group, and that tissue removal was believed to be
both more complete and more often to the appropriate depth with the microdebrider,
as opposed to being too shallow or too deep.
Our study is limited by the lack of randomization and the participation
of several different surgeons in different hospitals, and is thus subject
to bias in terms of both patient population and surgeon and operating room
proficiency. We have attempted to reduce bias by having the majority of cases
in both groups done by the same resident using the same methods of timing
and blood loss estimation. Curette adenoidectomies were done with freshly
sharpened instruments to provide for optimal tissue removal. Our results are
in accordance with those from a prospective randomized trial for complete
adenoidectomy.9
We believe that the true advantage of the microdebrider for partial
adenoidectomy lies in its precision, which cannot be quantified using the
results of this or any other study to date. Given the rarity of complications
from adenoidectomy, an impractically large number of study participants would
be required to show a difference in complication rates between the 2 procedures.
CONCLUSIONS
Partial adenoidectomy with the microdebrider is faster than partial
adenoidectomy with curettes by 59%. Our results are in accordance with those
demonstrating a time advantage of the microdebrider in complete adenoidectomy
as well. We believe that the most important advantage to operating with the
microdebrider is the precise control of tissue removal, which is especially
useful in partial adenoidectomy. We have shown that partial adenoidectomy
with the microdebrider is faster than that with curettes, and our impression
is that due to greater control over tissue removal, it is safer as well.
AUTHOR INFORMATION
Accepted for publication January 8, 2002.
Corresponding author: J. Lindhe Guarisco, MD, Ochsner Clinic, Ear,
Nose, and Throat Department, 1514 Jefferson Hwy, New Orleans, LA 70121.
From the Department of Otolaryngology, Head and Neck Surgery, Ochsner
Clinic and Alton Ochsner Medical Foundation, New Orleans, La. Dr Guarisco
was a stockholder of Medtronic Xomed.
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