Modern Surgical Techniques for Adenoidectomy

MS ENT University Examination - 20 Marks

INTRODUCTION (2 marks)

INDICATIONS FOR ADENOIDECTOMY (2 marks)

• Adenoid hypertrophy causing nasal obstruction, obligate mouth breathing, hyponasal voice, snoring, and obstructive sleep apnea
• Recurrent acute adenoiditis (4 or more episodes in 6 months)
• Chronic adenoiditis failing conservative management
• Recurrent or chronic otitis media with effusion (with grommet insertion)
• Chronic rhinosinusitis - adenoid acts as bacterial reservoir obstructing mucociliary clearance
• Suspected benign or malignant nasopharyngeal neoplasm

PRE-OPERATIVE ASSESSMENT (1 mark)

• Lateral X-ray nasopharynx or nasal endoscopy to assess adenoid bulk
• Trial of intranasal steroids (2 months) if hyperplasia confirmed
• Examine soft palate for submucous cleft before surgery
• Polysomnography if obstructive sleep apnea suspected

GENERAL PRINCIPLES OF TECHNIQUE (1 mark)

• The choanae are fully opened
• The nasopharynx has a smooth, level contour
• The torus tubarius (Eustachian tube cushion) is preserved

SURGICAL TECHNIQUES (10 marks - Core Section)

1. Blind Curettage (St Clair Thomson's Curette) - Classical Method

• The surgeon introduces a suitable-sized adenoid curette (St Clair Thomson's) guided by the index finger of the non-dominant hand placed in the nasopharynx
• The blade is engaged against the posterior wall of the nasopharynx at the roof (choanal level)
• A firm, sweeping downward stroke removes the adenoid mass in one or more passes
• Haemostasis achieved by firm nasopharyngeal packing with a rolled gauze swab for 3-5 minutes
• The pack and curette are removed; the finger checks for residual tissue

• Blind procedure - unpredictable and higher blood loss (mean ~50 mL)
• Poor access to choanal adenoid and lateral bands - risk of recurrence and regrowth
• Risk of trauma to the Eustachian tube cushion (torus tubarius) - can cause ET dysfunction
• Cannot ensure complete removal
• Still the most common technique used worldwide (79.2% in the UK use digital palpation + blind curettage)

2. Suction Diathermy (Suction Coagulator) - Direct Vision Technique

• A 0° or 30° rigid endoscope is introduced transorally via the mouth gag and positioned at the soft palate level (or nasally) for direct nasopharyngeal visualization
• A suction coagulator (monopolar or bipolar) is used under direct vision to coagulate and suction the adenoid tissue
• Allows partial adenoidectomy - a ridge of inferior adenoidal tissue can be deliberately preserved to reduce the risk of VPI
• Haemostasis is simultaneous - the suction coagulator cauterises as it removes

• Direct vision - complete tissue visualization
• Minimal blood loss (mean ~4 mL vs ~50 mL with curettage - Scott-Brown's)
• Excellent haemostasis, negligible postoperative haemorrhage risk
• Can access choanal and lateral adenoid tissue
• Can perform conservative/partial adenoidectomy
• Cheaper than microdebrider

3. Microdebrider-Assisted Adenoidectomy (Powered Intracapsular Adenoidectomy)

• A powered microdebrider (shaver) with an angled blade (typically 40° or 60°) is used under direct endoscopic visualization
• The oscillating blade simultaneously cuts and aspirates adenoid tissue in a controlled manner
• Can be used for Powered Intracapsular Tonsillectomy and Adenoidectomy (PITA) - preserves the tonsillar/adenoid capsule as a biological dressing
• Haemostasis via suction cautery or bipolar forceps if needed

• Precise tissue removal under direct vision
• Complete access to all nasopharyngeal regions
• 20% faster than curettage technique (RCT evidence)
• Lower risk of damage to Eustachian tube and soft palate
• PITA variant - reduced postoperative pain and haemorrhage (capsule preserved)
• Potential for regrowth with PITA is the main drawback

4. Coblation Adenoidectomy (Controlled Ablation)

• The Coblation wand is introduced under direct endoscopic visualization
• Tissue is ablated at low temperature with simultaneous coagulation
• Can be used as a combined tonsillectomy-adenoidectomy instrument (same wand)
• Complete adenoid removal even in difficult areas

• Significantly reduced thermal injury to surrounding tissue
• Less postoperative pain compared to conventional electrocautery
• Less blood loss and more complete adenoid removal vs. curettage
• Single-use instrument - eliminates risk of infection transmission (prion disease, etc.)
• Suitable for revision adenoidectomy
• Particularly cost-effective when combined with coblation tonsillectomy (same wand)

• High unit cost (limits use as sole adenoidectomy procedure)
• Data on pain reduction vs. cold dissection are mixed (Cochrane review of 9 trials found no significant differences)

5. Endoscopic Adenoidectomy (Transnasal/Transoral) - Modern Gold Standard for Direct Vision

• Transoral: 0° or 30° Hopkins rod endoscope placed above the soft palate
• Transnasal: Endoscope passed transnasally for direct nasopharyngeal visualization
• Combined with any of the above instruments (suction diathermy, microdebrider, coblation)
• Radiofrequency volume reduction is a recent refinement (published outcomes over 7 years, 3450 cases: mean operative time 15 min, mean blood loss 31 mL)

• Complete visualization of the nasopharynx
• Access to lateral bands, choanal adenoid, and peritubal adenoid tissue
• Precise haemostasis
• Reduced regrowth and revision surgery rates
• Ability to assess completeness of removal in real-time

6. Laser Adenoidectomy

• KTP (Potassium Titanyl Phosphate) laser: Associated with a high risk of nasopharyngeal stenosis - largely abandoned
• Gold laser: Small series show lower stenosis risk; limited clinical experience
• CO2 laser: Used occasionally; requires laser-safe anaesthesia
• All single-use instrument techniques (including laser) abolish potential risk of infection transmission

7. Bipolar Cautery / Harmonic Scalpel

• Bipolar cautery: Precise coagulation with less tissue injury; used with operating microscope or bayonet forceps
• Harmonic Scalpel: Uses ultrasonic vibration to transfer mechanical energy sufficient to break hydrogen bonds; results are similar but conflicting vs other techniques

COMPARISON TABLE OF TECHNIQUES (2 marks)

COMPLICATIONS OF ADENOIDECTOMY (2 marks)

• Primary/reactionary haemorrhage (within 24 hours) - most feared; rising pulse + vomiting dark blood = occult haemorrhage; return to OT for electrocautery or postnasal pack
• Anaesthetic complications
• Injury to Eustachian tube opening

• Secondary haemorrhage (>24 hours) - usually due to infection/sloughing
• Nasal regurgitation (transient)

• Velopharyngeal insufficiency (VPI) - hypernasality; risk in submucous cleft
• Adenoid regrowth (~1%) - requires revision adenoidectomy
• Nasopharyngeal stenosis (especially with KTP laser)
• Grisel's syndrome - atlantoaxial subluxation/torticollis from prevertebral fascia inflammation
• Eustachian tube dysfunction
• Cervical spine subluxation (higher risk in Down syndrome)
• Halitosis (common early)

POST-OPERATIVE CARE (1 mark)

• Majority of children may be safely discharged same-day with appropriate surgical and anaesthetic techniques, preemptive fluid replacement, antiemetics, and analgesia
• Safe discharge within 20 min of LMA use is technically feasible but not preferable
• Watch for occult haemorrhage (rising pulse, dark vomit)
• Soft diet, analgesia (paracetamol ± ibuprofen), avoid hot foods/drinks
• Halitosis resolves within 2 weeks as the adenoid bed heals

SUMMARY (for quick recall)

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 2 - Adenoidectomy chapter (direct-vision technique comparisons and meta-analysis data)
• Cummings Otolaryngology Head and Neck Surgery - Adenoidectomy procedure and complications
• Schwartz's Principles of Surgery, 11th Ed - Adenoids and Adenoidectomy, p. 650
• Endoscopic radiofrequency adenoidectomy - 7-year prospective series (Scientific Reports, 2025)