Adenoidectomy Treatment & Management

No good evidence supports any curative medical therapy for chronic infection of the adenoids. Systemic antibiotics have been used long-term (ie, 6 wk) for lymphoid tissue infection, but eradication of the bacteria failed. In fact, with the current trend of resistant bacteria, the use of prophylactic or long-term antibiotics has been decreased to prevent the formation of resistant bacteria.

Some studies indicate a benefit with using topical nasal steroids in children with adenoid hypertrophy. Studies indicate that while using the medication, the adenoid may shrink slightly (ie, up to 10%), which may help relieve some nasal obstruction. However, once the topical nasal steroid is discontinued, the adenoid can again hypertrophy and continue to cause symptoms. In a child with nasal obstructive symptoms with or without presumed allergic rhinitis, a trial of topical nasal steroid spray and saline spray may be considered for effective control of symptoms.

At this time, several surgical methods of removing the adenoid are available.

Excision through the mouth

Most commonly, the adenoid is removed through the mouth after placing a mouth appliance to open the mouth and retract the palate. A mirror is used to see the adenoids because they are behind the nasal cavity, as shown in the image below. Through this approach, several instruments can be used.

• Cold surgical techniques

  • Adenoid curette: The most standard and conventional successful method of removal is using an adenoid curette, shown below. The adenoid curette has a sharp edge in a perpendicular position to its long and occasionally curved handle. Remove the adenoids using this sharp-edged blade by feel after placing it in position in the nasopharynx. Various sizes of curettes are available to accommodate the various sizes of nasopharynges. Control hemostasis with packing and electrocautery. Different sizes of adenoid curettes, with the curette blade on the inside superior surface. Curvature at the end of a curette. Long view of an adenoid curette, showing the entire length of the instrument.
  • Adenoid punch: An adenoid punch, shown below, is a curved instrument with a chamber that is placed over the adenoids. The chamber is closed, and a knife blade surgically removes the adenoids, which are then deposited in the chamber and removed with the instrument. Various sizes of instruments are available for the various sizes of nasopharynges. Control hemostasis with packing and electrocautery. End view of adenoid punches showing different-sized ends of the instruments and different positions of the sliding blade doors from left to right. The blade door of the instrument on the left is closed, the blade door of the middle instrument is halfway open, and the blade door of the instrument on the right is completely open. Long view of adenoid punches, showing entire lengths of the instruments.
  • Magill forceps: A Magill forceps, shown below, is a curved instrument used to remove residual adenoid tissue, usually deep in the choana and encroaching on or into the posterior nasal cavity, after attempted removal with curettes or adenoid punches. Magill adenoid forceps used for the removal adenoids in the choanae that are jutting into the posterior nasal cavity, which are difficult to reach.
• Electrocautery with a suction Bovie

  • The second technique is using electrocautery with a suction Bovie, depicted in the image below, to remove the adenoid tissue or shrink the adenoids. The suction Bovie has a hollow center to suction blood or secretions and a rim of metal contact for coagulation, shown below. This instrument can be set for pure coagulation or for coagulation and cutting. Long view of a suction cautery instrument. Tip of a suction cautery instrument viewed from the end, with blue non–heat-transferring casing, silver metal cautery, and center hollow tube for suctioning.
  • Some consider the pure coagulation setting time consuming. The chard adenoid tissue can obstruct the suction, requiring repeated cleaning, which slows the procedure.
  • The coagulation/cutting combination method appears to be a quicker way to ablate the adenoid tissue. However, when using the cutting method, the transfer of energy to the surrounding tissues is greater, which can potentially cause more neck stiffness following the procedure.
• Surgical microdebrider: Other surgeons have used the surgical microdebrider in this position (see below). Some consider it equally or more effective. Bleeding certainly occurs during the actual removal, but the total reported blood loss has been similar to using the traditional curette. The surgical microdebrider has been advocated for removing adenoid tissue that is difficult to reach using other techniques. The additional cost of the microdebrider setup and tip is also a consideration. Different sizes of adenoid curettes, with the curette blade on the inside superior surface.
• Laser: The Nd:YAG laser has been used for the resection of adenoids. This technique has caused nasopharyngeal scarring and is best avoided.
• Coblation: Many authors have described using coblation to ablate the adenoid tissue. It is effective but may take increase time to remove the tissue, especially if significantly enlarged. The additional cost of the coblator setup and tip is also a consideration

Excision through the nose

The only useful technique for removing the adenoids through the nasal cavity is with the suction microdebrider. With this procedure, bleeding may occur and it must be controlled with either packing or suction cautery.

Determine if the patient has a family history of a bleeding or coagulation problem. Obtain the patient's own version of his or her coagulation history by asking about a history of frequent or severe nosebleeds, if any problematic bleeding has occurred with previous surgeries, or if easy bruising occurs. Schedule a hematological evaluation or consultation for patients with a possible bleeding or coagulation abnormality.

Before performing an adenoidectomy, obtain a detailed history of the patient's speech pattern. If the speech sounds abnormal, obtain a speech evaluation prior to surgery. Inspect the palate for any evidence of occult or obvious submucous cleft palate and for an overt cleft palate. A submucous cleft palate occurs in 1 in 1200 children. Signs of a submucous cleft palate include the presence of a bifid uvula; an attenuated medial raphe of the soft palate, which may appear as a blue line in the center of the palate; and a V-shaped notching of the hard palate.

If a large adenoid pad is acting as a physical structure against which the nasopharyngeal musculature (ie, the velopharynx) closes and if this adenoid pad is removed, children can develop a condition characterized by a failure to close their nasopharyngeal musculature (ie, the velopharynx) during swallowing or speech. Usually, the otolaryngologist recognizes a form of cleft palate, recognizes an obvious craniofacial syndrome (eg, Treacher Collins, Pierre Robin sequence) associated with palatal cleft problems, or hears hypernasal speech.

Other craniofacial syndromes (eg, velocardiofacial syndrome, Kabuki syndrome) occasionally remain unrecognized because their features are mild. Children with velocardiofacial syndrome have down-sloping palpebral fissures; small, oval-shaped, fishlike mouths; and pseudohypertelorism. These clinical features may be mild. Chromosomal testing for velocardiofacial syndrome, the abnormality of which consists of a deletion of the long arm of chromosome 22, is available. Frequently, these children are recognized only when they develop prolonged hypernasal speech following adenoidectomy.

Other children with neuromuscular disorders may be at risk for developing VPI following adenoidectomy, although the risk is not well quantified. These neuromuscular disorders include Arnold-Chiari malformation, Down syndrome, myotonic dystrophy, pseudobulbar palsy, and other neuromuscular disorders that could decrease palatal function.

For patients with potential or true hypernasal speech, weigh the benefits of adenoidectomy against the possibility of VPI and the possible need for speech therapy or additional surgery following adenoidectomy. In many of these patients who have nasal airway obstructive symptoms and decreased function of their palatal muscles, only remove the superior portion of the adenoids near the choana, leaving a bulk of tissue inferior to aid in closure of the velopharynx.

Ten percent of patients with Down syndrome have atlantoaxial joint laxity and are at risk of subluxation during suspension at the time of surgery. With children aged 3-4 years and older, perform a flexion-extension radiographic series prior to surgery to evaluate for this possible abnormality. If found, perform adenoidectomy with the head in a neutral position.

Children with neuromuscular diseases often have more difficulty with complications (eg, aspiration, pneumonia) following adenoid or adenoidal/tonsillar surgery performed while under general anesthesia. These complications are observed more commonly with tonsillar surgery; however, discussing the possibility of complications with the parents preoperatively is also necessary when performing an adenoidectomy.

Because children have an appliance to hold the mouth open during surgery, examine the condition of their teeth. Often, this surgery is performed in children aged 5-8 years who are losing their temporary teeth. Warn parents about loose teeth and the possibility that these teeth may be removed at the time of surgery.

Adenoid tissue rarely regrows, but advise parents of this possibility prior to surgery. The exact mechanism is unknown but may be related to incomplete removal.

For adenoidectomy, once the technique has been determined, only a few routine intraoperative procedures should be considered.

Always evaluate the palate for a submucous cleft. This preoperative evaluation may be difficult based on the disposition of the child. Use the techniques described in Preoperative details.

The question has been posed whether suctioning the stomach following removal of the adenoids, or tonsils for that matter, is necessary. Reports conflict as to the effect of gastric suctioning on postoperative nausea and vomiting. However, if the procedure caused significant bleeding into the stomach, removing it to prevent possible nausea and vomiting is prudent.

Consider sending the adenoid tissue for pathological evaluation. The chance of finding something other than plain lymphoid tissue in a sample that was not in question is virtually nonexistent, calling into question the need to send all specimens for routine gross or microscopic evaluation. Certainly perform a histological evaluation any time a lesion other than lymphoid tissue is suggested or any time the patient is receiving immunosuppressive medications. Pathologic evaluation is now under the discretion of the surgeon and pathologist.

Children usually recover well following an adenoidectomy. Often, they have no or only short-term pain or discomfort. Most otolaryngologists allow children to have normal diets once they have recovered from the general anesthetic. The amount of rest recommended for patients postoperatively varies from a few days to a week.

Patients may have some nasal congestion from swelling and scab formation in the nasopharynx, which resolves in a few days to weeks. Persistent congestion may be caused by concomitant allergic rhinitis. Intranasal steroids may hasten the resolution of persistent congestion, regardless of its cause.

Following adenoidectomy, children may develop a sore throat, especially when swallowing or speaking. When performing these functions, the palate must abut the posterior wall of the nasopharynx, where the adenoids were removed, potentially causing discomfort from the raw postoperative area.

In addition, children may develop hypernasal speech (ie, VPI) following the procedure. This is observed in at least half the patients. Speech usually reverts to normal 2-4 weeks following surgery but may require treatment if it persists (see Complications).

A scheduled follow-up visit (usually within 1-4 wk after surgery) is at the discretion of the surgeon. Recent literature describes a follow-up phone call by a nurse to supplant the postoperative office visit in children without concerns or complications, especially if the patient lives far away from the surgeon. If no problems exist, no continued follow-up care is needed.

Complications following adenoidectomy are rare and are listed in the order of occurrence.

Bleeding

The first complication is immediate bleeding from the site, which occurs in 0.4% of cases. Some moderate epistasis can be controlled with a vasoconstrictive agent (eg, oxymetazoline). Bleeding significant enough to mandate a return to the operating room occurs in 4 in 1000 patients. Significant delayed bleeding, observed in roughly 2% of tonsillectomy patients, is not observed with adenoidectomy.

Velopharyngeal insufficiency

VPI, observed in 0.03-0.06% of cases, occurs as a result of incomplete closure of the palate to the posterior and lateral nasopharyngeal wall, where the adenoids had previously been located. VPI is observed transiently in more than half the patients undergoing an adenoidectomy and usually resolves in 2-4 weeks. Persistent VPI (ie, > 3 mo) occurs in 1 in 1500-3000 adenoidectomies. Persistent VPI occurs more often in children who have generally decreased muscle tone or a known palatal abnormality (see Preoperative details). Some recommend performing a partial adenoidectomy, leaving the inferior portion of the adenoid pad, in patients at high risk for VPI. Treatment initially consists of speech therapy for as long as 12 months, depending on the severity of the VPI. Surgery is required in 50% of persistent cases.

Torticollis

Because the adenoids are removed from the posterior wall of the nasopharynx over the spine and superior constrictor muscle, children can have a stiff neck or spasm of the neck, occasionally with torticollis. Torticollis is a rare occurrence. Warm compresses, a neck brace, and anti-inflammatory medications may be helpful for relieving the spasm and pain.

Nasopharyngeal stenosis

Nasopharyngeal stenosis, which rarely occurs, consists of circumferential contracture of the pharynx in the region of the Waldeyer ring. This contracture is more common with T&A than with adenoidectomy alone because the combined procedure results in a larger and more circumferential area of denuded pharyngeal surface with greater potential for scar contracture. The clinical presentation is usually nasal obstruction or hyponasal speech. Repair usually consists of palatal or pharyngeal rotational flaps of unaffected mucosa and is fraught with failure.

Atlantoaxial subluxation from infection (Grisel syndrome)

Infection or inflammation in the nasopharynx following adenoidectomy is an extremely rare occurrence that can cause vertebral body decalcification and laxity of the anterior transverse ligament between the axis and atlas. Spontaneous subluxation is observed approximately 1 week after surgery and is associated with pain and torticollis. Treatment includes consultation with a neurosurgeon and stabilization of the cervical spine.

Mandibular condyle fracture

If subluxed during surgery, the mandibular condyle can be fractured. This is an extremely rare occurrence.

Eustachian tube injury

Eustachian tube injury can occur, but this is an extremely rare complication.

Chronic persistent otitis media

Gates et al have the most quoted article concerning the effectiveness of adenoidectomy for preventing the recurrence of chronic (ie, > 2 mo) serous otitis media in children aged 4-9 years.^[8] In a study consisting of 491 children published in the New England Journal of Medicine in 1987, Gates et al showed that not only was adenoidectomy effective independent of the size of the adenoids, they showed that a hierarchy existed in effectiveness for preventing ear fluid from returning when treated with surgery.^[8] In that study, Gates et al showed that adenoidectomy and tympanostomy tube placement were better than adenoidectomy and myringotomy, which was better than tympanotomy tube placement alone, which was better than myringotomy alone.^[8]

Maw and Speller, Paradise et al, and others have confirmed the findings reported by Gates et al.^{[3, 9]} The improvement appears to be a 30-50% reduction in the recurrence of fluid if the adenoids are removed in conjunction with other surgeries for persistent otitis media.

Recurrent otitis media

The evidence supporting adenoidectomy for recurrent otitis media is weaker than that for persistent otitis media. However, a modest 30% improvement in resolution of recurrent infections occurred when the adenoids were removed.

Chronic sinusitis

A study by Lee and Rosenfeld in 1997 showed that children with sinusitis improved after adenoidectomy, and improvement was independent of the weight of the adenoids.^[4] Other studies show that size is important to the resolution of symptoms of sinusitis.

Nasal airway obstruction

If the adenoid is enlarged and blocking the nasal cavity, the symptoms of nasal airway obstruction, snoring, and nasal congestion should resolve after an adenoidectomy.

The future controversy related to adenoidectomy appears to be the determination of the age at which adenoidectomy is safe, based on the possibility of the immunological benefit of the adenoids. Some studies indicate that markers for the production of antibodies that may help fight viruses are observed in the adenoids. No studies show that immunity is impaired in a child following adenoidectomy. However, adenoidectomy in children younger than 1 year is rare and adenoidectomy in children younger than 2 years is uncommon. The adenoid tissue itself is not usually significantly enlarged until age 18-24 months. Certain individuals who have adenoid hypertrophy and complete nasal obstruction as young as age 7-8 months have difficulty breathing and do not feed well. These children benefit from adenoid removal to improve their breathing and ability to eat.

Because a certain set of children with chronic and acute otitis media appears to have persistent problems after tube placement or has early extrusion of the tubes with recurrence of ear disease and benefits from adenoidectomy, identification of these children prior to placement of their first set of tubes may be beneficial. However, this may be difficult to determine.

Despite the numerous techniques available for removing the adenoids, the standard and generally most successful method of using the curette for removal appears to be the most widely performed procedure. Because adenoidectomy is a common procedure, new techniques will always be evaluated in attempts to improve the medical or surgical therapy for the diseases for which the adenoids are responsible.