RIGID ENDOSCOPIC EVALUATION OF
D REGMI, N N MATHUR, M BHATTARAI
Dept.of otolaryngology & head and neck
B P Koirala Institute of Health Sciences,
Introduction By: Dr.Roohia
Disscussion By: Dr. Krishna
Adenoidectomy is a most common surgical
procedure perfomed in childrens.
Conventional curettage commonly used
technique in adenoidectomy.
Adenoids is primarily a
disease of young
children occurs mainly
between the ages of 3
and 5 years.
1994 140,000 U.S.
children under the age
of 15 had
This is down from a
peak of over 1 million
in the 1970’s
1867 Wilhelm Meyer reports removal of
“adenoid vegetations” through the nose with a
In 1885, Gottstein described the first adenoid
Pearl & Manoukian had reportedly removed
adenoids viewing it indirectly with a laryngeal
Canon popularized the use of rigid endoscopy in
visualising and removal of adenoid remanants
after blind currett.
Wan et al have introduced the transoral
adenoidectomy under endoscopic guidance.
In 1992, Becker et al, reported the use of
endoscopy assisted adenoidectomy.
Adenoids is the
mass of lymphoid
tissue situated at
the junction of roof
& post. wall of
The mass of
lymphoid tissue is
when it is
The adenoid develops
as a midline structure by
fusion of 2 lateral
Adenoids begin forming
in 3rd month of fetal
Fully formed by 7 month
of gestation. Continue to
grow up to 5yrs of life.
It usually undergoes
atrophy by puberty (1314 yrs)
Adenoids is a nasopharyngeal
lymphoid tissue is a part of the
Waldeyer’s ring which includes:
Extend to the fossa of
Rosenmuller and to the
eustachian tube orifice
as Gerlach’s tonsil.
Base- at junc of roof &
post. Wall of
Apex- towards septum
No crypts & capsule.
Vertical folds extends
forwars & laterally from
bursa/bursa of luschka)
1. Ascending pharyngeal artery
2. Ascending palatine artery
3. Pharyngeal branch of internal
4. Artery of pterygoid canal
5. Contributions from tonsillar
branch of facial artery
6. basishpenoid artery
Venous drainage from the adenoid
is through the pharyngeal plexus
which in turn drain into the internal
Nerve supply: pharyngeal plexus.
Lymphatics: in to retropharyngeal
&pharyngo maxillary space L.nodes.
Upper deep jugular
nodes, Parapharyngeal nodes. there
are no afferents.
Exposed to ingested
or inspired antigens
passed through the
structure is divided
into 4 compartments:
area, mantle zone of
follicle, and the
germinal center of
the lymphoid follicle
Membrane cells and
cells are involved in
transport of antigen
from the surface to the
Antigen is presented
to T-helper cells
T-helper cells induce B
cells in germinal
center to produce
Secretory IgA is
Involved in local
adenoids can contribute to recurrent sinusitis and chronic
persistent or recurrent ear disease because they can harbor a
Recurrent or persistent middle ear effusion
Infants have a natural lack of immune function and poorer
eustachian tube function.
Bacteria-irritation of the eustachian tube lining, resulting in
dysfunction,/chronic low-grade infection in the middle ear
adenoid appears to act as a reservoir of infection.
same pathogenic bacteria in the adenoids were cultured from
the middle meatus near the anterior sinus drainage site
Nasal airway obstruction
physically blocking the back of the nose. add to sinusitis itself
by blocking normal nasal flow posteriorly,
1) Environmental pollution.
3) Bad Hygiene
4) Poor general health
1) Recurrent upper respiratory
2) Chronic tonsillitis.
A) Nasal obstruction,
1) Mouth breathing.
3) Difficulty of suckling and
4) Nasal tone of the voice
B) Adenoid facies:
face due to absence
of the nasolabial
Open mouth and
Hitched up upper
gums, pyorrhea, and
Inactive ala nasi.
High arched palate .
C) Mucopurulent anterior and
posterior nasal discharge.
D) Sleep disturbances:
2) Sleep apnea .
3) Nocturnal enuresis due to
E) Respiratory manifestations:
1) Irritant cough
2) Recurrent pharyngitis, laryngitis, and
F) Recurrent ear aches and deafness due
obstruction of the eustachian tubes
otitis media and middle ear effusions
G) Symptoms of throat : due to recurrent
pharyngitis,tonsillitis, mouth breathing
recurrent sore throat,dysphagia,voice
change,poor eaters, ,malnutrition.
H) Decreased mental performance due
sleep disturbances, hypoxia, defective
recurrent respiratory infections causing
long periods of absences from school.
I) Feeding problems: loss of
and vomiting due to swallowed
J) Skeletal changes :including pigeon
Harrison’s sulci, and depressed
Lateral x-ray of the
GRADE I- adenoid tissue filling 1/3rd
ht of choana
GRADE II-upto 2/3rd
GRADE III- from 2/3rd to nearly all but
not completely filling of choana
GRADE IV-with complete choanal
Modified josephson et al
Airway , Choana, Eustachian tube
A0- no adenoids
A1-25% airway block C1-50%
E0-no ET block
1. Middle ear effusions and otitis
2. Recurrent respiratory infections.
3. Disturbed learning, easy fatigue,
genaral poor health
4.older children; increased ventilatory
resistance leads to
moderate cardiac enlargement
RVH to Corpulmonale
Medical: for mild/infrequent symp
Adequate nutrition, Antibiotics, Anti
decongestant drops,steroid sprays like
These children must undergo a complete
course of medical treatment. (2wks)
The ideal drug of choice is penicllin
Ampicillin or Amoxycillin can
be administered in doses ranging 40 - 50
mg /kg body weight.
Erythromycin & cefalosporins can be
Current clinical indicators from AAOHNS:
◦ 4 or more episodes of recurrent purulent
rhinorrhea in prior 12 months in a child <12. One
episode documented by intranasal examination
or diagnostic imaging.
◦ Persisting symptoms of adenoiditis after 2
courses of antibiotic therapy. One course of
antibiotics should be with a beta-lactamase
stable antibiotic for at least 2 weeks.
◦ Sleep disturbance with nasal airway obstruction
persisting for at least 3 months
◦ Hyponasal or hypernasal speech
◦ Otitis media with effusion >3 months or second
set of tubes
◦ Dental malocclusion or orofacial growth
disturbance documented by orthodontist
◦ Cardiopulmonary complications including cor
pulmonale, pulmonary hypertension, right
ventricular hypertrophy associated with upper
◦ Otitis media with effusion over age 4
Epidemics of polio.
Cleft palate, short palate
Types of adenoidectomy
The Nd: YAG laser :has additionally been
accustomed to take away the adenoids.
However, this method is responsible for
scarring of tissue and it is generally avoided.
Adenoid punch device: An adenoid punch is
really a curved device having a chamber
that's placed within the adenoids. The
chamber includes a knife blade sliding-door
to section from the adenoids which are then
housed within the chamber and removed
using the instrument.
POST OP CARE
1. Immediate general care
(a) Keep the patient in coma position until fully
recovered from anaesthesia.
(b) Keep a watch on bleeding from the nose and
(c) Keep check on vital signs, e.g.
pulse, respiration and blood pressure.
When patient is fully recovered he is to take
liquids, e.g. cold milk or ice cream.
3. Nasal saline drops
Pain, locally in the throat and referred
to ear, can be relieved by analgesics like
paracetamol. There is no dysphagia and
patient is up and about early.
5. Antibiotics A suitable antibiotic can
be giv en orally or by injection for a
Patient is usually sent home 24 hours
after operation unless there is some
complication. Patient can resume his
normal duties within 2 weeks
POST OP COMPLICATIONS
1. Haemorrhage, usually seen in immediate postoperative period.
2. Injury to eustachian tube opening.
3. Injury to pharyngeal musculature and vertebrae. Care
should be taken when operating patients of Down's
syndrome as 10-20% of them have atlanto-axial
4. Griesel syndrome. Patient complains of neck pain
and develops torticollis. Mostly it is due to spasm of
paraspinal muscles, but can be due to atlanto-axial
dislocation requiring cervical collar and even traction.
5. Velopharyngeal insufficiency.
6. Nasopharyngeal stenosis due to scarring.
7. Recurrence. This is due to regrowth of adenoid tissue