Adenoidectomy

Adenoidectomy is the surgical procedure in which the adenoids are removed. Adenoids are lymphoid tissue located in the back of the nose. They are often not understood by the lay public or by physicians who are not otolaryngologists because they are not observed during routine physical examinations because of their location. Although the tissue composition of adenoids is the same as that of the tonsils, the diseases associated with infected adenoids differ from the diseases associated with infected tonsils, based on their location. This causes additional confusion because the adenoids are often simultaneously grouped with the tonsils when reporting outcomes in scientific journals.

An adenoidectomy is often associated with other surgical procedures (eg, tonsillectomy, placement of tympanostomy tubes). In fact, throughout most of the 20th century, tonsillectomies were usually performed in conjunction with adenoidectomies. Despite more than 50 years of research, some controversy is still associated with the indications for adenoidectomy. Most often, an adenoidectomy is performed in pediatric patients. The focus of this article is pediatric adenoidectomy.

Adenoidectomy was probably first performed in the late 1800s when Willhelm Meyer of Copenhagen, Denmark, proposed that adenoid vegetations were responsible for nasal symptoms and impaired hearing. However, tonsillectomy has been performed for at least 2000 years; Celsus first described the procedure as early as 50 BC. The hidden location of the adenoid certainly had an impact on the historical timing of discovery.

The 2 operations (tonsillectomy and adenoidectomy) were routinely performed together beginning in the early part of the 1900s, when the tonsils and adenoids were considered reservoirs of infection that caused many different types of diseases. Tonsillectomy and adenoidectomy (T&A) was considered a treatment for anorexia, mental retardation, and enuresis or was performed simply to promote good health.

As odd as those indications sound, they actually can be explained. Children with failure to thrive have improved appetites and gain weight after tonsillectomy and adenoidectomy (T&A) because their throats are typically no longer chronically sore and they can breathe better. Children who have persistent middle ear effusions often have hearing loss and associated speech delay and may be classified as mentally challenged. Adenoidectomies help resolve ear fluid problems, speech delays, and perceptions of low intelligence. Enuresis has actually been studied and listed as an indication for tonsillectomy and adenoidectomy (T&A) because large tonsils and adenoids block normal breathing through the nose and mouth, which interrupts sleep architecture and decreases normal brain and brainstem control of urinary function.

Additionally, almost every child experiences improved health and more energy following tonsillectomy and adenoidectomy (T&A). Based on the broad range of indications for surgery, tonsillectomy and adenoidectomy (T&A) became almost universal for school-aged children in the early 1900s.

In the 1930s and 1940s, the widespread use of tonsillectomy and adenoidectomy (T&A) became controversial because (1) antimicrobial agents were developed to help treat tonsillitis and adenoiditis, (2) the fact that a natural decline in the incidence of upper respiratory infections in older school-aged children became evident, (3) some studies were published showing that tonsillectomy and adenoidectomy (T&A) was ineffective, and (4) an increased risk of developing poliomyelitis following tonsillectomy and adenoidectomy (prior to the vaccine) was recognized. Once the opinion pendulum began to swing towards avoidance of surgery, good prospective clinical trials, which have been performed over the last two decades, were required to prove to the medical and lay community that good indications for tonsillectomy and adenoidectomy (T&A), tonsillectomy alone, and adenoidectomy alone, exist.

Frequency

Obtaining current information is difficult because adenoidectomy is usually performed in outpatient settings, for which data are not well regulated or recorded. Good information was recorded during the 1970s and 1980s when the procedure was mainly performed in inpatient settings. In the United States in 1971, more than 1 million tonsillectomy and adenoidectomy procedures, tonsillectomies alone, or adenoidectomies alone were performed, with 50,000 of these procedures consisting of adenoidectomy alone.

In comparison, in 1987, 250,000 combined or single procedures were performed, with 15,000 consisting of adenoidectomy alone. However, starting in this time period, outpatient tonsillectomy and adenoidectomy (T&As) and adenoidectomies were being performed more often, which may account for a possible underestimation of the total number of surgeries performed. In current practice, almost all adenoidectomies alone are performed in outpatient settings unless other issues or medical problems require hospital admission or an overnight stay. Additionally, tonsillectomy and adenoidectomy (T&A) is also usually performed in an outpatient setting, unless the child is young or other issues or medical problems require hospital admission or an overnight stay.

Probably the best source to obtain the true incidence and frequency of the procedures is data from all the managed health care companies throughout the United States. Tonsillectomy and adenoidectomy (T&A) is considered the most common major surgical procedure in the United States.

Adenoids, shown in the images below, are on the posterior nasopharyngeal wall posterior to the nasal cavity, shown below. They develop from a subepithelial infiltration of lymphocytes in the 16th week of gestation. They are a component of the Waldeyer ring of lymphoid tissue, which is a ring of lymphoid tissue in the oropharynx and nasopharynx that consists mainly of the adenoids, the palatine tonsils, and the lingual tonsils.

Adenoids are present at birth and then begin to enlarge. They, along with the tonsils, continue to grow until individuals are aged 5-7 years. The adenoids usually become symptomatic, with snoring, nasal airway obstruction, and obstructed breathing during sleep, when children are aged approximately 18-24 months. By the time children reach school age, the adenoids normally begin to shrink, and, by the time children reach preteen or teenage years, the adenoids are usually small enough for the child to become asymptomatic.

At birth, the nasopharynx and, thus, the adenoids, are accessible to many organisms. The establishment of the upper respiratory tract is initiated at birth. By the time children are aged 6 months, lactobacilli, anaerobic streptococci, actinomycosis, Fusobacterium species, and Nocardia species are present. Normal flora found in the adenoid consists of alpha-hemolytic streptococci and enterococci, Corynebacterium species, coagulase-negative staphylococci, Neisseria species, Haemophilus species, Micrococcus species, and Stomatococcus species. The adenoids can become infected and harbor pathogenic bacteria, which may lead to the development of disease of the ears, nose, and sinuses.

Based on the current literature, adenoids can contribute to recurrent sinusitis and chronic persistent or recurrent ear disease because they can harbor a chronic infection. The type and amount of pathogenic bacteria seem to vary based on the disease present and the age of the child.[1]

Overall, the most commonly cultured bacteria have been Haemophilus influenzae, group A beta-hemolytic Streptococcus, Staphylococcus aureus, Moraxella catarrhalis, and Streptococcus pneumoniae, usually in that order. The author has found resistant bacteria of the 3 most common pathogens of otitis media and rhinosinusitis (ie, H influenzae, M catarrhalis, S pneumoniae) in children with those diseases.

Adenoidectomy, regardless of size of the adenoids, has improved the signs and symptoms of rhinosinusitis and has reduced the recurrence of persistent middle ear effusions or infections in studies evaluating children older than 3 years.

Recurrent or persistent middle ear effusion

Recurrent or persistent otitis media is multifactorial and age-dependent. The 2 main features accounting for disease in the middle ear are immune function and the function of the eustachian tube. Infants have a natural lack of immune function and poorer eustachian tube function, both of which improve over time. Many children outgrow their ear infections because of this maturity. Persistent ear infections or fluid problems in children are usually related to persistent immature eustachian tube function, dysfunction related to chronic adenoid infection, or dysfunction of the eustachian tube related to congestion from allergic rhinitis. Several studies indicate that eustachian tube function is improved and fluid collection is prevented following adenoidectomy, independent of the size of the adenoids.

The studies over the last 2 decades that evaluated the pathophysiology of the adenoids' role in causing ear infections are confusing. Initially, the confusion regarded the mechanism of eustachian tube dysfunction; the debate was about whether eustachian tube dysfunction was related to a physical obstruction or the harboring of a chronic infection. Several authors compared the amount of bacteria in the adenoids of children with disease (eg, recurrent ear infections, persistent ear infections, nasal airway obstruction). Often, the control subjects for the children with middle ear effusions were different, consisting of either children with adenoid hypertrophy alone without ear infections or, occasionally, children without any head and neck pathology or infection.

Pillsbury et al demonstrated more pathogenic bacteria in the adenoid beds of patients with recurrent otitis media than in the adenoid beds of patients cultured for persistent serous otitis media or hypertrophy.[2] Additionally, Brodsky and Koch cultured more bacteria from the adenoids of patients with either recurrent otitis media or persistent otitis media than from the adenoids of patients without infections in the head and neck.[3]

However, Brodsky et al found the same amount of pathogenic bacteria in the adenoids of patients with otitis media and rhinosinusitis, regardless of size, as in the adenoids of patients with only adenoid hyperplasia causing nasal airway obstruction. Even more confusing is the fact that Maw and Speller found the same amount of pathogenic bacteria in the adenoids and tonsils of patients with otitis media with effusion as was found in patients without any head and neck disease.[4]

Regardless of the mechanism, adenoidectomy, independent of the size of the adenoid, has been shown to be effective for resolving chronic persistent otitis media with effusion and possibly recurrent otitis media in children older than 4 years. Adenoidectomy in children younger than 3 years has been shown to be safe, but its effectiveness for treating recurrent otitis media or rhinosinusitis is not proven.

Whether the bacteria that are harbored in the adenoids cause irritation of the eustachian tube lining, resulting in dysfunction, or the harbored bacteria cause a chronic low-grade infection in the middle ear space, resulting in persistent fluid or recurrent infections, remains unclear.

Chronic sinusitis

For patients with chronic sinusitis, the adenoid appears to act as a reservoir of infection. This is based on the improvement observed following adenoidectomy independent of the weight of the adenoids in children with symptoms of chronic sinusitis as shown by Lee and Rosenfeld in 1997.[5] Additionally, Brodsky et al showed that the same pathogenic bacteria in the adenoids were cultured from the middle meatus near the anterior sinus drainage site.[6] McClay also showed that resistant bacteria were found in the adenoid bed.[7]

Nasal airway obstruction

Enlarged adenoids can also cause nasal airway obstruction, with clinical symptoms of nasal congestion, snoring, and breathing through the mouth, by physically blocking the back of the nose. Symptoms of nasal airway obstruction may overlap with chronic sinusitis symptoms, and the physical obstruction may add to sinusitis itself by blocking normal nasal flow posteriorly, resulting in a stasis of secretions and an obstruction in the sinus outflow tract.

Often, enlarged adenoids (with the tonsils) can obstruct breathing patterns in children and can cause obstructive breathing, including apneas, at night. Obstruction is based on their size alone. However, when enlarged, the adenoids may have a chronic infection.

Children who benefit from adenoidectomy can have several different clinical presentations. Children who have recurrent or persistent otitis media may benefit from adenoidectomy independent of the size of the adenoid pad. Hence, these children may or may not present with nasal airway obstructive symptoms (eg, nasal congestion, snoring, sleeping with open mouths) because their adenoids may not be enlarged. However, often these children do have some form of nasal congestion or snoring. The respected prospective studies to date only include children aged 3-4 years and older. The effectiveness of adenoidectomy for resolving otitis media in children younger than 3-4 years who have small- or moderate-sized adenoids has not been addressed.

Children can also present with symptoms of chronic or recurrent sinusitis. These clinical symptoms may include postnasal drainage or purulent anterior rhinorrhea, cough, fever, facial pain, and nasal congestion.

Additionally, children may have nasal airway obstructive symptoms without signs of acute or chronic infections. The symptoms include nasal airway obstruction, snoring, and mouth breathing. When enlarged, the adenoid blocks normal nasal cavity airflow and causes chronic mouth breathing, which can lead to palatal and dental abnormalities.

Indications for adenoidectomy are as follows:

• Enlargement causing nasal airway obstruction, which can result in obstructive breathing, obstructive sleep apnea symptoms, and chronic mouth breathing (could result in palatal and dental abnormalities)

• Recurrent or persistent otitis media in children aged 3-4 years and older

• Recurrent and/or chronic sinusitis

Lee and Rosenfeld demonstrated that signs and symptoms in children with recurrent sinusitis are improved by adenoidectomy, independent of the weight of the adenoid.[5] The fact that children with enlarged adenoid pads blocking the choana have improved signs and symptoms of chronic sinusitis following adenoidectomy is not in doubt. However, pediatric rhinologists have some concern that a school-aged child with a small adenoid pad and CT scan evidence of chronic sinusitis may not improve if only adenoidectomy is performed. In 1999, a presentation at the American Academy of Pediatrics confirmed this concern by finding that adenoidectomy usually controlled symptoms and infections in children with large adenoids; however, if the adenoid was small and CT scan evidence of chronic sinusitis was present, not as many children improved, leading the authors to believe these children would benefit from initial procedures of adenoidectomy and endoscopic sinus surgery.

Van den Aardweg et al evaluated the effect of adenoidectomy in decreasing the number of upper respiratory infections (URIs) for 2 years following the procedure in children aged one to six years. Of 111 children at 13 hospitals, both the surgery and no surgery groups each had 8 episodes of URIs in the study period. Results suggest adenoidectomy is not an effective treatment for recurrent respiratory infections in children. However, the study did find the prevalence of upper respiratory tract infections decreased over time in both groups.[8]

The adenoid is on the posterior wall of the nasopharynx, which lies posterior to the nasal cavity. The adenoid lies over the base of the skull and clivus area, shown below.

The adenoid overlies mucosa that overlies the superior constrictor muscle in this area. The adenoid can be large enough to encroach on the posterior oropharyngeal wall. Lateral to the adenoid is the torus tubarius, shown below, which is the medial orifice of the eustachian tube. The superior wall of the nasopharynx abuts the choanae (ie, the posterior portion of the nasal cavity). The adenoid can be enlarged enough to obstruct the choanae. The percentage of obstruction of the choanae is often used to size the adenoids.

Attached to the floor of the nose and choanae is the soft palate, depicted above. The soft palate is the anterior inferior wall of the nasopharynx. The soft palate is responsible for regulating the amount of airflow into the nasal cavity and nasopharynx from the oral cavity and oropharynx by opening and closing the posterior and lateral nasopharyngeal wall, where the adenoid is housed. This sphincter of muscles is called the velopharynx. The amount of airflow into the nasal cavity regulates the resonance of the voice. Too much airflow through the nose results in hypernasal speech, and too little airflow results in hyponasal speech (see Velopharyngeal Insufficiency).

If the adenoid changes in size or is removed, the muscles of the palate must accommodate to a new gap size to close off the nasopharynx. An inability of the velopharyngeal muscles to accommodate results in velopharyngeal insufficiency (VPI).

For more information about the relevant anatomy, see Tonsil and Adenoid Anatomy.

No absolute contraindications exist, except for conditions in which general anesthesia cannot be performed.

Relative contraindications for total adenoidectomy

See the list below:

• A severe bleeding disorder, which could be overcome by preoperative, intraoperative, and postoperative coagulation medicines and techniques, is a relative contraindication to adenoidectomy.

• A child at risk of developing VPI, which might be associated with a short palate, submucous cleft palate, true cleft palate, muscle weakness or hypotonia associated with a neurological disorder, velocardiofacial syndrome, or Kabuki syndrome, is another relative contraindication. These conditions may be overcome with partial adenoidectomy or preoperative planning for muscular speech therapy following adenoidectomy (see Velopharyngeal Insufficiency).

• Atlantoaxial joint laxity is observed in 10% of children with Down syndrome. Surgery in the neutral position or following stabilization by neurosurgery may make it possible to perform the surgery without injury to the patient.

See the list below:

• No standard preoperative laboratory evaluation exists for adenoidectomy. Most surgeons do not order preoperative laboratory tests.

• Intraoperatively, the adenoid can be sent for pathologic and histologic evaluation. It can also be sent for culture to evaluate the pathogens present.

See the list below:

• Lateral neck radiograph

  • The main imaging study to evaluate the adenoid is a lateral neck radiograph, as in the image below.

    Normal lateral neck x-ray film evaluating the adenoids and nasopharynx.

  • Over the years, various dimensions in the nasal cavity and nasopharynx have been measured to assess the degree of obstruction caused by adenoids, as shown below.

    Different measurements for the choanae show (1) measurement of the adenoids, (2) horizontal measurement of the nasopharyngeal stripe followed by horizontal measurement of the adenoid pad and diagonal thickness of the adenoid pad, (3) horizontal measurement from the choanae to the adenoids and the adenoid pad, and (4) the thickness of the palate in comparison to the thickness of the nasal pharyngeal air stripe.

  • Confusion related to the usefulness of the lateral neck radiograph and its capability to help evaluate adenoid size is based partly on the 4 different techniques described.

  • The goal of all techniques is to correlate the measurements with the clinical efficacy of adenoidectomy. Most techniques focus on the size of the nasopharyngeal stripe, which indicates the amount of airflow through the nasopharynx. This measurement seems to be most accurate. When the nasopharyngeal stripe is half the size of the soft palate, significant obstruction occurs. However, studies indicate that improvement in rhinosinusitis symptoms or recurrent or persistent otitis media occurs as a result of adenoidectomy, independent of the size of the adenoid. Thus, for those indications, knowing the size of the adenoid preoperatively has no bearing on surgical judgment and is unnecessary.

• CT scan

  • CT scan is not normally used to evaluate the adenoids. However, when a CT scan is performed to evaluate the sinuses, the choana and nasopharynx are occasionally imaged, providing information on the size of the adenoids.

  • If the CT scan does not involve the nasopharynx, information on the adenoids may be obtained from the plain sagittal scout film performed along with the CT scan.

• CT scan or MRI

  • If the adenoids look abnormal or if a mass is present in the nasopharynx in an older child or in an adult, an imaging study (eg, CT scan, MRI) is obtained to rule out a lesion other than an adenoid.

  • The adenoids, by the time an individual is a teenager or older, usually regress in size and are not usually causing an obstruction.

See the list below:

• Flexible or rigid nasopharyngoscopy

  • To evaluate the adenoid in a clinic, a flexible or rigid nasopharyngoscopy can be performed.

  • The progression of evaluation with nasopharyngoscopy along the floor of the nose can be observed in the images below.

    A rigid rhinoscopy photograph of the left anterior nasal cavity. The middle turbinate is superior in the midline, and the inferior turbinate is to the right. The septum is to the left. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks.
    A rigid rhinoscopy photograph taken in the mid portion of the left nasal cavity showing the septum on the left, the inferior turbinate on the right, and the middle turbinate superiorly. The choanae is seen in the dark area in the center. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks.
    A rigid rhinoscopy photograph taken two thirds of the way back along the floor of the nose of the left nasal cavity. This photograph shows the septum on the left, the choanae straight ahead, and the posterior portion inferior turbinate to the right. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks.
    A rigid rhinoscopy photograph taken all the way back into the choanae of the left nasal cavity. The photograph shows the septum on the left, the small adenoids on the posterior superior wall of the nasopharynx in the center, and the eustachian tube orifice on the right. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks.

• Biopsy

  • Occasionally, if a nasopharyngeal mass is encountered in an older child or an adult or if the lesion of the nasopharyngeal mass of tissue in a younger child does not appear exactly like adenoid, a biopsy can be performed to ensure a correct diagnosis.

  • Biopsy is rarely necessary; however, if it is necessary in young children, perform the biopsy in an operating room.

  • Teenagers and adults may tolerate a biopsy of the nasopharyngeal mass with adequate topical anesthesia in the clinic.

  • If any finding indicates that the lesion may be vascular, obtain preoperative imaging with a CT scan, MRI, or magnetic resonance angiography and perform the biopsy in the operating room.

The adenoid is composed of lymphoid tissue, similar to a lymph node, without an afferent blood supply, as shown below.

The adenoid has germinal centers where the antibodies are produced. See the images below. The epithelium over the adenoid is the same as the respiratory epithelium in the nasal cavities and sinuses, which is a pseudostratified, ciliated, columnar epithelium.

The immunological function of the adenoid has been studied by evaluating the types and numbers of different immunological components, such as immunoglobulins (antibodies), antigen-presenting cells, neutrophils, and dendritic cells. Additional function of the adenoid may be based on the ratio of respiratory to squamous epithelium and the amount of functioning cilia present, which help nasal flow. All of these immunological and protective functions are detrimentally affected by chronic infection in the adenoids.

Adenoid size is often graded similarly to tonsil size as 1+, 2+, 3+, or 4+. This grading of the observed size of the adenoid while the patient is in the supine position during surgery coordinates to 25%, 50%, 75%, or 100% obstruction of the choana, respectively. Alternatively, the percentage of obstruction of the choana can be mentioned and ranges from 0-100%. Remember that the degree or obstruction of the choana appears different depending on if the adenoids are visualized while the patient is in the sitting position in the clinic or if the patient is lying supine in the operating room with the palate reflected superiorly, depicted below.

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.

See the list below:

• 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.[9] 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.[9] 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.[9]

Maw and Speller, Paradise et al, and others have confirmed the findings reported by Gates et al.[4, 10] 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.[5] 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.