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 curette 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 obstructive 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 adenoids obstructing the posterior choanae is common in Setting: Tertiary referral center. children with adenoid hypertrophy. Traditional adenoidectomy 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 enables 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 endoscopically (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, Meyer.A1 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.

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©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 senior 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 posterior choanae after curette adenoidectomy (Table 1). Nine other The objective of adenoidectomy is to remove the hyper- patients had significant residual obstructing adenoid tis- trophic adenoid tissue that causes nasal airway stenosis sue remaining high in the nasopharynx (grade 2 or 3). leading to pathological restriction of nasal airflow.

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Dissatisfaction with the traditional curette adenoidectomy in adequately and safely achieving this clearance Table 1. Intranasal Adenoid Findings has led to the development of alternative techniques that have been made possible by developments in fiberoptics No. With Intranasal 3,5,6 No. of Extension of and endoscopic instrumentation. Presenting Problem Patients Adenoid Tissue The main disadvantage of curettage is that it is a rela- tively “blind” technique that may lacerate the choanae Nasal obstruction 40 13 Sinusitis 23 15 and torus tubarius, gauge the nasopharyngeal mucosa, Recurrent otitis media 67 14 or skim the adenoid bulk, leaving behind obstructing tis- Total 130 42 sue, 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, Table 2. Airway Patency Assessment* under endoscopic vision, may be similarly traumatic. Insulated suction diathermy adenoid ablation has Maximum Grade of Airway Obstruction been a popular alternative.8 While suction diathermy ablation usually mini- Stage of Operation 0123 mizes blood loss, it may not address intranasal adenoid Preoperative 0 0 40 90 tissue, is slow, and carries the potential risks of cicatri- After curettage 30 49 39 12 zation and collateral burns as does the use of the carbon After adjuvant shaver 68 62 0 0 dioxide laser, which also requires full laser precautions. The powered-shaver method has been applied in *Data are given as number of patients. a number of ways. It may be the primary technique, used as an adjunct to curettage, or coupled with other Today there is a wide choice of methods available to methods. perform this common operation. While it is tempting to Route of visualization and access to the adenoid may presume that applying new technology is preferable to “old- be transoral, transnasal, or a combination. The transoral fashioned” techniques, the benefits ought be critically quan- procedure is performed using an angled mirror and spe- tified and assessed before accepting a change. This study cially developed 40° curved blades with the cutting win- has demonstrated that in up to 39% of children with clini- dow on the circumference. Transnasal direct endo- cally significant adenoid hypertrophy, curette adenoid- scopic vision combined with the powered shaver allows ectomy does not achieve adequate removal of obstruc- precise removal of obstructive tissue while preserving mu- tive adenoid tissue, especially when there is intranasal cosa and normal nasopharyngeal structures. Intranasal extension of adenoid or a bulky mass of adenoid high in adenoid tissue and tissue high in the nasopharynx may the nasopharynx. In such cases the use of powered- be readily identified and removed. The oscillating cut- shaver technique enables better clearance of obstructive ting action of the shaver blade minimizes bleeding and adenoid. the continuous suction maintains a clear view enhanc- We therefore recommend that endoscopic visual- ing safety. In cases that require partial adenoidectomy ization during adenoidectomy is worthwhile and that in the precision and safety of this technique are of particu- some cases the powered-shaver adenoidectomy pro- lar advantage. Further, by operating through the nose vides more reliable restoration of nasal patency. there is no need for hyperextension of the neck in patients, such as those with Down syndrome, who may have Accepted for publication December 5, 2001. congenital instability of the cervical spine. By operating Corresponding author and reprints: Prof Thomas Havas, with the video attachment on the telescope, the theater FRACS, Suite 506, 253 Oxford St, Bondi Junction, Sydney, staff may be more involved in the operation, and trainee New South Wales 2022, Australia. teaching is facilitated. Restrictions of powered-shaver adenoidectomy to REFERENCES date have largely been due to problems inherent in adapt- ing an orthopedic instrument to nasal surgery. These in- 1. Thornval A. Wilhelm Meyer and the adenoids. Arch Otolaryngol Head Neck Surg. cluded heavy handpieces with blade width and angles un- 1969;90:383. 2. Wang DY, Clement PA, Kaufman L, Derde MP. Chronic nasal obstruction in chil- suitable to a crowded nose, leading to damage to normal dren: a fiberoptic study. Rhinology. 1995;33:4-6. nasal structures and poor maneuverability in the naso- 3. Parsons DS. Rhinologic uses of powered instrumentation in children beyond si- pharynx.6 We found that even in small children, trans- nus surgery. Otolaryngol Clin North Am. 1996;29:105-114. nasal surgery using the lightweight magnum handpiece 4. Di Martino E, Mlynski G, Mlynski B. Effect of adenoid hyperplasia on nasal airflow [in German]. Laryngorhinootologie. 1998;77:272-274. and 2.9-mm blade with a triangulated window kept clear 5. Huang HM, Chao MC, Chen YL, Hsiao HR. A combined method of conventional with continuous suction irrigation, combined with a and endoscopic adenoidectomy. Laryngoscope. 1998;108:1104-1106. 2.7-mm telescope, enabled a highly controlled adenoid 6. Yanagisawa E, Weaver EM. Endoscopic adenoidectomy with the microdebrider. clearance. Useful supplementary techniques were the Ear Nose Throat J. 1997;76:72-74. transoral placement of an oxymetazoline-soaked sponge 7. Koltai PJ, Kalathia AS, Stanislaw P, Heras HA. Power-assisted adenoidectomy. Arch Otolaryngol Head Neck Surg. 1997;123:685-688. low in the nasopharynx before shaving and ensuring that 8. Wright ED, Manoukian JJ, Shapiro RS. Ablative adenoidectomy: a new tech- the shaver suction was off during passage of the blade nique using simultaneous liquifaction/aspiration. J Otolaryngol. 1997;26: through the nose. 36-43.

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