A combined method of conventional and endoscopic adenoidectomy

Adenoid hypertrophy is a well-known cause of nasal obstruction and recurrent serous otitis media in children.1 Adenoidectomy with or without other surgical procedures such as tonsillectomy or tympanostomy tube insertion is a commonly performed treatment for these disorders. The conventional procedure for adenoidectomy has been well outlined in the literature.2, 3 In this procedure, an adenotome or adenoid curette is used to remove the adenoid tissue. Many modifications of this basic surgical procedure have also been reported.4, 5 However, neither the conventional procedure nor the modifications allow the performance of the operation under direct visualization. Endoscopic equipment is commonly used in sinus surgery because the endoscope allows the operation to be performed under direct visualization. In this paper, we introduce a combined method of conventional and endoscopic adenoidectomy for the treatment of nasal obstruction due to adenoid vegetation. Using this technique, adenoid tissue can be removed completely without damage to other structures. With proper use of this method, the patency of the nasopharynx and the orifice of the eustachian tube can be established. From 1994 to 1996, 15 patients (10 boys and five girls) who suffered from nasal obstruction, mouth breathing, and snoring during sleep were treated using a combined method of conventional and endoscopic adenoidectomy at the Taipei Municipal Women and Children Hospital in Taiwan. The patients' ages ranged from 3 to 12 years, with a mean age of 5.4 years. Prior to treatment, physical examination demonstrated a clear and patent nasal airway in all patients except for two, whose symptoms were combined with sinusitis. All patients received a lateral view skull radiographic examination that revealed that a huge adenoid mass obstructed the nasopharynx (Fig. 1). All of the operations were performed under general anesthesia via endotracheal intubation. In this procedure, the patient is put supine in Rose's position with the head extended. The mouth is opened with a Dingmann mouth gag. Disinfection of the face and oral cavity is performed to avoid unnecessary contamination. The nasal mucosa is shrunken with 1:1000 epinephrine-rinsed cotton pledgets, which are removed 10 minutes after application. While the soft palate is retracted using a Hurd tonsil retractor, an adenoid curette is applied to the nasopharynx transorally and the main bulk of adenoid is removed. Care is required during this process in order to avoid injury to the choana and muscular layer of the posterior pharyngeal wall, which could result in massive bleeding. Subsequently, a 4-mm or 2.7-mm, 0d̀ or 30d̀ endoscope is inserted transnasally into the nasopharynx. Residual adenoid tissue at the superior portion of the nasopharynx and the orifice of the eustachian tube, which will be obstructed, is usually noted at this time. Under endoscopic guidance, it is removed piece by piece using either a straight or 45d̀ Blakesley forceps (Fig. 2). The patency of the nasopharynx and the orifice of the eustachian tube can be demonstrated by direct visualization without damage to other structures. Hemostasis can also be evaluated and achieved via direct endoscopic visualization. Epinephrine- and H2O2-rinsed gauze is inserted into the nasopharynx transorally or transnasally following adenoid tissue removal to compress the wound and is removed following achievement of hemostasis. The above procedure can be repeated until hemostasis is achieved completely. In our experience, no other technique has been needed to stop bleeding. A huge adenoid obstructing the nasopharynx (arrow). There were no postoperative complications such as nasopharyngeal hemorrhage noted in any of the patients, and all of them were discharged the day after the operation. Thirteen patients complained of nasal obstruction due to crusting and nasal mucous swelling caused by instrumentation. After close follow-up and local treatment, the symptoms of nasal obstruction subsided completely within 1 week in all of these patients. About 3 months after operation, a lateral view skull radiographic examination was performed and revealed a patent nasopharynx in all patients (Fig. 3). Traditionally, most surgeons use an adenotome or adenoid curette to remove hypertrophic adenoid tissue. However, this procedure does not always produce complete removal of the adenoid, especially in the superior and peritubal portions of adenoid that obstruct the nasopharynx and the orifice of the eustachian tube. Overly aggressive curettage may result in inadvertent damage to muscle, the choana, or other structures. Other modifications of this technique have been reported. Pearl and Manoukian4 removed the choanal adenoids under indirect visualization using a laryngeal mirror. Drake and Fischer5 performed peritubal adenoidectomy using a curved uterine curette. However, none of these techniques allow the adenoidectomy to be performed under direct visualization. Endoscope and cup forceps were passed transnasally to visualize and remove the residual adenoid. In 1992 Becker et al.6 reported the use of endoscopic adenoidectomy for the relief of serous otitis media. They used endoscopic equipment to remove the hypertrophic adenoid tissue transorally and transnasally, and concluded that endoscopic removal of enlarged adenoid in selected young adolescents and adults may be effective for treatment of recurring otitis media and persistent serious otitis. Nevertheless, their study focused only on patients with massive adenoid hypertrophy concealing the eustachian tube orifice. After operation the patency of the nasopharynx was shown by radiograph (arrow). The use of endoscopic equipment allows the adenoid to be removed piece by piece. However, in patients with a very large adenoid, endoscopic removal requires more time than conventional surgery, which prolongs the need for anesthesia and increase its risk. In these patients, conventional surgical methods can remove the main bulk of the adenoid mass. Thus the combination of conventional and endoscopic approaches in these patients will shorten the operative time required to remove the adenoid completely. On the other hand, direct endoscopic visualization reduces the likelihood of damage to other structures by excessive excision and hemorrhage due to to residual adenoid tissue. Direct visualization allows direct identification and treatment of the source of bleeding and is therefore highly suitable for children because it reduces the risk of hemorrhage. Becker et al.6 used suction cautery and KTP laser to achieve hemostasis under endoscopic control. These procedures can be performed accurately and without difficulty under endoscope if necessary. Hemostasis was achieved in all of our patients solely through compression with epinephrine- and H2O2-rinsed gauze. Because of its visual restrictions the conventional method of adenoidectomy has inherent limitations during removal of adenoid tissue. Fortunately, with the combination of endoscopic equipment, these limitations can be overcome. There are several advantages in the combined approach of conventional and endoscopic adenoidectomy. First, the procedure can remove a huge adenoid completely without prolonging the operative time. Second, the use of an endoscope provides a direct and clear view that allows the surgeon to remove adenoid tissue accurately, evaluate and stop bleeding effectively, and reduce unnecessary trauma. Thus the combined approach of conventional and endoscopic adenoidectomy is an effective and safe method for treatment of enlarged adenoids. It is recommended for patients with adenoid hypertrophy with or without recurrent otitis media and sinusitis.