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Obstructive Adenoid Tissue an Indication for Powered-Shaver Adenoidectomy

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Obstructive Adenoid Tissue an Indication for Powered-Shaver Adenoidectomy ORIGINAL ARTICLE Obstructive Adenoid Tissue An Indication for Powered-Shaver Adenoidectomy Thomas Havas, FRACS; David Lowinger, FRACS Objectives: To quantify the incidence of intranasal ex- ered-shaver adenoidectomy. The presence of intranasal tension of adenoid tissue and residual adenoidal obstruc- adenoid tissue was also recorded. tion of the posterior choanae following traditional cu- rette adenoidectomy to determine the efficiency of adenoid Results: Following traditional curette adenoidectomy, 51 curettage and the usefulness of intraoperative endo- (39%) of 130 patients had residual obstructive adenoid with scopic examination and powered-shaver adenoidec- 42 patients (32%) having occlusive intranasal adenoid tis- tomy in achieving better postnasal patency. sue. Having determined the presence of remaining obstruc- tive tissue with intraoperative nasal endoscopy in these 51 Design: Prospective intraoperative endoscopic evalua- patients, complete airway patency was achieved with pow- tion of the posterior choanae and nasopharynx of a case ered-shaver adenoidectomy. series of 130 patients before and after curette and powered- shaver adenoidectomy. Conclusion: The presence of intranasal extension of ad- enoids obstructing the posterior choanae is common in Setting: Tertiary referral center. children with adenoid hypertrophy. Traditional adenoid- ectomy is ineffective in removing this tissue and may also Patients: One hundred thirty consecutive pediatric pa- leave obstructive tissue high in the nasopharynx. Intra- tients with obstructive adenoidal hypertrophy undergo- operative nasal endoscopy allows assessment of the com- ing adenoidectomy. pleteness of surgery. Powered-shaver adenoidectomy en- ables complete removal of obstructive adenoid tissue Main Outcome Measures: The degree of residual post- thereby ensuring postnasal patency. nasal obstruction due to adenoid tissue was assessed en- doscopically (grades 0-3) after curette and adjuvant pow- Arch Otolaryngol Head Neck Surg. 2002;128:789-791 DENOIDS, which are naso- methods, including powered-shaver ad- pharyngeal lymphoid tis- enoidectomy.3 sue forming part of the While there is a perception that shaver Waldeyer ring, were ini- adenoidectomy is more effective in clear- tially described in 1868 by ing adenoid tissue compared with curettage, AMeyer.1 Present from early gestation, ad- this has yet to be objectively assessed. We enoid growth continues until about 6 years undertook this study to evaluate the ad- of age, after which atrophy occurs. Adenoi- equacy of removal of obstructive adenoid dal hypertrophy during childhood may both with the traditional curette technique to de- fill the nasopharynx and extend through the termine whether endoscopically guided posterior choanae into the nose, resulting powered-shaver adenoidectomy would at- in nasal airway stenosis, impeding airflow. tain better clearance. There is a significant relationship between the endoscopically determined size of ob- RESULTS structive adenoid tissue and symptomatic nasal obstruction in children.2 Sequelae in- One hundred thirty consecutive patients clude mouth breathing and rhinorrhea, requiring adenoidectomy were included in sleep-disordered breathing, speech anoma- this study. Seventy-nine were male and 51 lies, feeding difficulties, chronic sinusitis, female, with ages ranging from 10 months and craniofacial growth anomalies. to 14.1 years. These clinical manifestations may be The indication for adenoidectomy readily remedied with removal of obstruc- was adenoidal hypertrophy causing nasal tive hypertrophic adenoid tissue to restore obstruction in all cases. In 40 cases the in- From the Department of airway patency. The widely used conven- dication for surgery was obstruction alone. Otolaryngology, Sydney tional curette adenoidectomy was first de- Twenty-three patients had associated per- Children’s Hospital, scribed in 1885.1 Dissatisfaction with this sistent sinusitis and 67 had associated re- Sydney, Australia. technique has prompted the use of other current otitis media. (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 128, JULY 2002 WWW.ARCHOTO.COM 789 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 PATIENTS AND METHODS 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 indepen- PATIENTS dent colleague (ear, nose, and throat [ENT] consultant or se- nior ENT registrar). The presence of persisting viable intra- One hundred thirty consecutive paediatric patients with ob- nasal adenoid and/or residual obstructive nasopharyngeal structive adenoid hypertrophy undergoing adenoidectomy adenoid tissue was recorded for each side of the nose. The were included in this study. All patients were assessed pre- degree of obstruction at the posterior choanae was standard- operatively with transnasal endoscopy and determined to have ized according to the numerical grading scale (grades 1-3). obstructive adenoid hypertrophy (grades 2 and 3). Only pa- Patients with a grade 2 or 3 remaining stenosis then tients in whom a partial adenoidectomy was intentionally per- underwent completion of the adenoidectomy using a pow- formed, such as those with palatal dysfunction, were ex- ered shaver. cluded. All adenoidectomies were performed by or under the supervision of the senior author (T.H.). TECHNIQUE The following grading system was used to standard- ize the endoscopic assessment of the degree of airway ob- A transnasal powered-shaver adenoidectomy technique struction due to adenoid tissue: guided by transnasal videoendoscopy was used. The shaver used is the 3-in-1 XPS Xomed Power System with the light- Grade Degree of Obstruction weight magnum-scaled handpiece and a 2.9-mm Tricut 0 0-30 blade with straight-through suction irrigation (Medtronic 1 30-59 Xomed Surgical Products, Jacksonville, Fla). 2 60-99 The theater setup and positioning is as for a standard 3 100 functional endoscopic sinus surgery: First, oxymetazoline hy- “Significant obstruction” was determined to be stenosis of drochloride–soaked 1-inch pledgets are placed into each side the posterior choanae of 60% or more (grades 2 and 3) based of the nose for a few minutes to vasoconstrict and enhance on clinical experience and nasal airflow models.4 access. A sponge soaked in oxymetazoline is placed, per- Operations were performed under general anesthe- orally, into the nasopharynx and left there until the proce- sia. When tonsillectomy or myringotomy were performed dure is completed. This assists hemostasis and prevents oc- and tubes were placed during the same anesthetic, these cult blood loss into the oropharynx. Using the 0° 2.7-mm rigid were completed prior to adenoidectomy. telescope (4 mm in older children), the posterior choanae and nasopharynx are assessed. Under endoscopic vision the shaver METHODS cannula is passed into the nose with the suction switched off to allow passage through to the adenoid without traumatiz- In each case, the patient was anesthetized and an oral en- ing the turbinates or septum. The suction is then turned on dotracheal tube or laryngeal mask placed. The child was and obstructive tissue removed under constant endoscopic placed supine in the Rose position with a small pillow un- vision with care not to lacerate the torus tubarius. The cut- der the shoulders to allow slight neck extension and was ting and aspirating action of the shaver removes both ad- covered with sterile drapes. enoid tissue and blood, providing a clear view. Using a 0° 2.7-mm rigid fiberoptic telescope (Storz, Working from proximal to distal, intranasal adenoid Tuttlingen, Germany), obstructive adenoidal hypertro- and hypertrophic nasopharyngeal adenoid are removed un- phy was confirmed. With a Boyle-Davis mouth gag splint- til the surgeon is satisfied with the clearance. Pledgets soaked ing the mouth open, the palate and uvula were inspected in either hydrogen peroxide or oxymetazoline are then di- and palpated to exclude a soft palate cleft. An appropriate- rectly applied, under endoscopic vision, to any bleeding sized unguarded adenoid curette was then used to remove point until hemostasis is established. The nasopharyngeal adenoid tissue. The surgeon was allowed to palpate the ad- sponge is removed and routine postoperative and dis- enoid bed and repeat the curettage until satisfied with com- charge protocol followed. pleteness of removal. The adenoid bed was then suctioned Owing to the study protocol, there was an obvious in- and a nasopharyngeal sponge placed for a few minutes for crease in operative time when both curette and shaver tech- hemostasis. The sponge was then removed, a Y-suction cath- niques were used. However, we were certain that we had eter passed through the nose to ensure removal of any loose achieved complete clearance of the nasal airway in every clot or tissue, and the nasopharynx inspected to ensure ces- patient. There was no primary or secondary bleeding in any sation of bleeding. case, nor any delay in discharge from the hospital. Following traditional curette adenoidectomy, each These 51 patients had further adenoid removal with the of the 130 patients was assessed endoscopically. Over- small joint shaver, achieving complete postnasal pat- all, 51 patients (39%) had remaining obstructive ad- ency (grades 0 and 1) (Table 2). enoid (grade 2 or 3). Forty-two (32.3%) of the 130 patients had residual COMMENT intranasal adenoid tissue still occluding the
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