Endoscopic Adenoidectomy

Meyer first characterized the adenoid, a nasopharyngeal lymphoid tissue that is part of the Waldeyer ring, in 1868. Adenoidectomy is one of the most commonly done surgeries on children today, either alone or in combination with tonsillectomy or the insertion of ventilation tubes. In 1885, the commonly used conventional curette adenoidectomy was first reported.

Though uncommon, complications such as hemorrhage, insufficient removal, eustachian tube stenosis, and nasopharyngeal stenosis are best avoided by accurate excision of adenoid tissue while preserving the integrity of nasopharyngeal structures. Dissatisfaction with standard techniques for removing adenoid tissue effectively and safely has led to the development of alternative treatments, such as endoscope guided power-shaver adenoidectomy.

 

What are Adenoids?

The adenoid is a single mass of tissue found at the back of the nose, where it connects to the throat. Although most people say "adenoids," as if there are several, there is only one adenoid.

The adenoid (also known as the pharyngeal tonsil) is a component of our immune system. Our immune system aids in the battle against microorganisms that cause sickness. Consider the adenoid to be a germ processing center. It teaches our bodies to distinguish different types of germs so that we can fight them more effectively.

 

Why do some children need to have their adenoid removed?

Your doctor may advise you to get your child's adenoid removed for a variety of reasons.

Today, the most common cause for adenoid removal in children is to help them breathe and sleep better. The adenoid develops overly large in certain children. This can happen for a variety of reasons, but we seldom know why it happens to a specific child. If the adenoid becomes too large, it might partially obstruct a child's breathing while sleeping. The adenoid can completely obstruct the back of the nose in extreme situations! This frequently produces loud snoring and, in certain cases, causes a child's sleep to be restless or fragmented, leading in poor focus throughout the day, behavioral abnormalities, and, in some cases, recurrent bedwetting. This is referred to as sleep apnea.

Removing the adenoid (and occasionally the tonsils) improves breathing significantly. To treat this condition, sometimes only the adenoid must be removed, and other times both the tonsils and adenoids must be removed.

Another typical reason for adenoid removal in children is recurrent ear infections. The adenoid is positioned in the back of the nose, adjacent to the Eustachian tube entrance. Normal Eustachian tube function is what keeps our ears healthy. When the tube becomes plugged or irritated, middle ear infections or fluid might develop. An enlarged or persistently infected adenoid can impair Eustachian tube function. Ear infections and fluid are less likely to arise when this type of adenoid is removed.

Recurrent nose infections are a less prevalent reason for adenoid removal. Some youngsters suffer from recurring sinus infections that are characterized by thick, green or yellow discharge that is present all of the time. This discharge may improve with antibiotics, but it frequently returns once the medications are discontinued. If left untreated for an extended length of time, this can develop to chronic sinus irritation. The adenoid is frequently removed to help manage this condition, but it does not prevent the common cold or every disease that produces nasal discharge.

 

What are the Signs & Symptoms of Enlarged Adenoids?

Kids with enlarged adenoids might:

• Have trouble breathing through the nose
• Breathe through the mouth (which can lead to dry lips and mouth)
• Talk as if the nostrils are pinched
• Have noisy breathing ("Darth Vader" breathing)
• Have bad breath
• Snore
• Stop breathing for a few seconds during sleep (obstructive sleep apnea), which can lead to disturbed sleep. This in turn can cause learning, behavioral, growth, and heart problems, and sometimes bedwetting.
• Have frequent or chronic (long-lasting) nose or sinus infections
• Have ear infections, middle ear fluid, and hearing loss

 

How are Enlarged Adenoids Diagnosed?

The doctor may inquire about, and then examine, your child's ears, nose, and throat, as well as feel the neck along the jaw. To gain a better look, the doctor may order X-rays or use a small telescope to view down the nose canal.

A doctor may prescribe many forms of treatment, such as tablets or liquids, for a suspected illness. To assist minimize swelling in the adenoids, nasal steroids (a liquid injected into the nose) may be administered.

 

How is the Adenoid Removed?

Adenoidectomy is a surgical technique that removes the adenoid. It is performed in the operating room under general anesthesia by an ear, nose, and throat surgeon. General anesthesia is relatively safe in this day and age, and your kid will be closely watched during the treatment. Although the adenoid is located in the back of the nose, it is removed through the mouth, leaving no visible scars.

Unlike the tonsils, your surgeon cannot totally remove all adenoid tissue in the back of the nose (though we can perform a decent job with today's equipment). As a result, the adenoid might "grow back" and produce symptoms again. However, it is extremely unusual for a youngster to require a second adenoid removal.

 

What is an Adenoidectomy?

The surgical removal of the adenoids is known as an adenoidectomy. Along with tonsil ectomy, it is one of the most common surgical operations performed on youngsters. Adenoidectomy may be recommended if enlarged adenoids affect your kid and do not respond to medication.

Several adenoidectomy procedures have been thoroughly reported in the literature. Adenoid curette guided by an indirect transoral mirror and a flashlight is a straightforward and rapid treatment that has long been used, but it involves a significant risk of recurrence unless performed by a skilled surgeon. Recently, curved suction electrical coagulators and curved microdebrider shavers transorally guided by a transoral indirect mirror or a 45-degree endoscope have been utilized effectively. Endoscopic adenoidectomy with a traditional adenoid curette has also been documented.

 Becker et al. excised adenoidal tissues transnasally and transorally while using endoscopic visualization. Koltai developed a power-assisted adenoidectomy procedure that did not need the use of a nasal endoscope, but Yanagisawa and Weaver employed the same technique but had trouble moving the microdebrider tip into the nasopharynx.

Each treatment has advantages and downsides; nevertheless, symptoms of adenoid hypertrophy may reoccur or even continue after the adenoid is removed.

 

Are there any Instructions I need to Follow Before Surgery?

Before surgery, your kid must be examined by his or her pediatrician or family doctor to ensure that he or she is in excellent health. Although this test can be performed at any time within 30 days of surgery, we encourage scheduling it as soon to the day of surgery as feasible. The doctor you see must fill out the History and Physical form that our office provides. The completed paperwork must be brought with you on the day of surgery.

For at least 3 days before surgery, you should not give your kid any pain or fever medicine other than Tylenol® (acetaminophen). Children's Motrin® and ibuprofen should be avoided before to surgery, although ibuprofen may be used to reduce discomfort following surgery.

 

Endoscopic Adenoidectomy Procedure

Patients were put under general anesthesia and orotracheal intubation was performed. The setup and posture in the operating room were normal for functional endoscopic sinus surgery. Pledgets soaked in 4% lignocaine and 1:10,000 adrenaline were used to decongest the nasal cavities. A mouth gag was used. The posterior choanae and nasopharynx were examined with a 0° 2.7 mm rigid telescope (4 mm for older children). A microdebrider with variable irrigating blade angles of 0, 15, 45, and 60° or a specific adenoid blade was utilized.

The unique adenoid blade is longer and features a window on the convex side for transorally adapting to the nasopharynx roof. Sinuscope and debrider were inserted into the same nostril, or the sinuscope was inserted into one nostril and the debrider into the other. In rare situations, sinuscope was introduced via the nose and an angled blade debrider was passed into the mouth cavity. In younger children, a transoral technique with a 45° scope and angled microdebrider blades or adenoid blades was used.

To avoid harm to the turbinates or the septum, the shaver cannula was inserted into the nose under endoscopic vision with suction turned off. The suction was then activated, drawing the adenoid tissue in and shaving it under continual endoscopic observation. The adenoidectomy was initiated high in the nasopharynx from the upper limit of adenoid tissue, which is frequently inaccessible with a typical curette.

Resection was continued on an equal level side to side until the inferior margin of the adenoid pad was reached. The shaver's cutting and aspirating action, along with simultaneous irrigation, eliminates both adenoid tissue and blood, allowing for a clean vision. Better control over the depth of adenoid removal is accomplished, preventing injury to underlying structures.

Hemostasis was achieved in a few cases by using pledgets soaked in hydrogen peroxide or by suction diathermy. A nasopharyngeal pack was applied for a few minutes before being withdrawn. The mouth gag had been removed. The patient was discharged the same day after receiving post-operative treatment. After a week, all patients were followed up on monthly basis for 6 months to a year. Endoscopic nasopharyngeal examination was performed during the follow-up visit to check healing and completeness of removal.

Adenoid size, operation time, blood loss, completeness and depth of removal, surgeon satisfaction, and complications were all documented intraoperatively. Adenoid size was classified as small to moderate (50 percent blockage), big (50-75 percent obstruction), or extremely large (>75 percent obstruction) based on the degree of nasopharyngeal obstruction seen on nasal endoscopy. On a stop watch, the operational time in minutes and seconds was recorded from the moment the mouth gag was fixed until it was withdrawn.

The difference in the amount of irrigating fluid utilized and the collected fluid in the vacuum flask was used to compute precise blood loss. The microdebrider's in-line irrigation device was employed during adenoidectomy. As a result, the precise amount of irrigating fluid from the saline bottle was recorded. At the completion of the process, the material collected from the suction canister was filtered to eliminate tissue, and the residual fluid, which included blood and irrigating fluid, was quantified.

The blood loss in milliliters was estimated by subtracting this quantity from the previous amount of saline used for irrigation. The amount of blood found on the nasopharyngeal pack following surgery was not quantified. The adenoid resection was graded as fair, good, or exceptional for completeness. When adenoid tissue was entirely resected superiorly up to the top of the nasopharynx, posterolaterally till the eustachian tube orifices, and anteriorly from the choanae, it was characterized as good.

When just a few adenoid tags were accidentally left behind, resection was assessed as good, and fair when significant adenoid remains were discovered post-operatively. Depending on the plane of tissue dissection achieved, the depth of resection was classified as shallow, sufficient, or excessive. Intraoperative problems, such as harm to nearby structures, might be evaluated in the operating room. His degree of happiness was recorded by the surgeon doing the treatment.

After a week, the patients were evaluated for discomfort, neck stiffness, speech abnormalities, and swallowing difficulties. Endoscopic nasopharyngeal examination was performed, and the effectiveness of adenoid removal was evaluated. The time necessary for the patient to return to his usual diet and activity was recorded. At the end of one year, ten patients were lost to follow-up. At the end of a year, 34 individuals were evaluated endoscopically to rule out nasopharyngeal stenosis. The data was collected and examined.

 

What can I expect after surgery?

The treatment normally takes between 20 and 30 minutes. Your doctor will contact you as soon as the procedure is completed.

After surgery, your kid will awaken in the recovery room. This might take anything from 45 minutes to an hour. When your kid is conscious, he or she will be transferred to the Short Stay post-operative section to finish his or her recuperation. You are permitted to accompany your child once he or she has been relocated to this section.

Children normally go home the same day after surgery, but your doctor may advise you to keep your kid in the hospital overnight in some situations (e.g., your child is under age 4 and had his or her tonsils removed). If your youngster stays overnight, one adult must also remain overnight.

For the first 24 hours following surgery, an upset stomach and vomiting (throwing up) are usual. If only the adenoid is removed (rather than the tonsils), your child's throat will be painful for a day or two following surgery. Even though their throat hurts a bit, most youngsters are able to eat and drink normally within a few hours of surgery. It is critical that your child consume enough of water following surgery. If your kid complains of neck ache, throat pain, or trouble swallowing, give him or her Tylenol® (acetaminophen) or Children's Motrin® (ibuprofen). Prescription pain relievers are not required.

Following adenoid removal, antibiotics are no longer frequently recommended. After surgery, your kid may develop a fever for 3-4 days. This is typical and not reason for concern. Neck pain, poor breath, and snoring are all frequent side effects of surgery. These symptoms will also subside during the first three weeks following surgery.

 

How should I take care of my child after surgery?

It is critical that you urge your youngster to drink enough of fluids. Keeping the neck wet reduces pain and helps to avoid dehydration (a dangerous condition in which the body does not have enough water). There are no dietary restrictions following endoscopic adenoidectomy. To put it another way, your youngster can eat whatever you regularly feed him or her.

In most circumstances, your kid will be able to resume normal activities within 1 or 2 days of surgery. There is no need to limit typical activities after your child has recovered. For one week after surgery, vigorous exercise (such as swimming and running) should be avoided.

 

What are the Alternatives to Having the Adenoid Removed?

Because your adenoids shrink as you age, you may notice that your nose and ear issues improve with time. Surgery will help these disorders heal faster, but it comes with a minor risk. You should consult with your surgeon about whether you should wait and see or have surgery right now. For some children, utilizing a steroid nasal spray to relieve nasal and adenoid congestion may be beneficial to try before deciding on surgery. Antibiotics are ineffective and only provide short-term relief from infected nasal discharge.

They cause negative effects and may promote antibiotic-resistant "super-bugs." Signing a consent document does not obligate your kid to have the procedure; you may change your mind at any moment. You can consult with your professional for a second opinion on the therapy. He or she will gladly arrange this for you. You might request a second opinion from another expert through your primary care physician.

There is no evidence that alternative therapies like homeopathy or cranial osteopathy assist with tonsillitis. You can consult with your professional for a second opinion on the therapy. He or she will gladly arrange this for you. You might request a second opinion from another expert through your primary care physician.

 

Will my child’s immune system be weaker if the adenoid is removed?

The adenoid is merely a minor component of our immune system. It turns out that our immune system may learn to detect pathogens in a variety of ways. Those who have their adenoid (and even their tonsils) removed have no more diseases on average than children who "keep" their adenoid. In fact, some children will experience less ailments, such as recurring sinus infections, after having their adenoid removed.

 

Conclusion 

Under direct endoscopic imaging, hypertrophic adenoid tissue in the nasopharynx, particularly those bordering on the nasal cavity, can be fully removed. Endoscopic adenoidectomy is a better option than traditional adenoidectomy since it allows you to choose how much adenoid tissue is removed.