Adenoid Adenoidectomy

1. SCOTT BROWN LEARNING
2020
CHAPTER – 26)ADENOID AND ADENOIDECTOMY
VOLUME-2
PAGE NO- 285 TO 293
PRESENTER- DR.M.PRABHAKARAN MS.,PG

2. INTRODUCTION
• Santorini described the nasopharyngeal lymphoid aggregate or
‘Luschka’s tonsil’ in 1724.
• Wilhelm Meyer coined the term ‘adenoid’ to apply to what he described
as ‘nasopharyngeal vegetations’ in 1870..
• Historically, the adenoid has been associated with upper airway
obstruction, as a focus of sepsis, and more recently with the persistence
of otitis media with effusion.

3. DEVELOPMENT OF THE ADENOID
• Lymphoid tissue can be identified at the 4 to 6 week gestational period, lying within the
mucous membrane of the
• roof and posterior wall of the nasopharynx. The adenoid is clearly identifiable during the
third month of gestation.
• The adenoid receives a rich arterial supply from branches of the facial and maxillary
arteries and the thyrocervical trunk.
• Venous drainage is to the internal jugular and facial veins.
• Lymphatic drainage is to the retropharyngeal lymph nodes and upper deep cervical
nodes, particularly the posterior triangle of the neck.

4. • Nerve supply is from sensory branches of the glossopharyngeal and vagus nerves.
• The adenoid is visible using magnetic resonance imaging
(MRI) from the age of 4 months in 18% of children.
• At 5 months of age, the adenoid could be identified in all of 290 children studied.
• Growth continues rapidly during infancy and plateaus between 2 and 14 years of
age.
• Regression of the adenoid occurs rapidly after 15 years of age in most children.
• The adenoid is at its relative largest in relation to the volume of the nasopharynx in
the 7-year old age group.
• Clinical symptoms are more common in a younger age group, due to the relative
small volume of the nasopharynx and the increased frequency of upper respiratory
tract infections.

5. IMMUNE FUNCTION OF
THE ADENOID
• The function of the lymphoid tissue of Waldeyer’s ring is to produce antibodies. The adenoid produces B-
cells, giving rise to IgG and IgA plasma cells.
• Exposure to antigens via the mouth and nose is an important part of natural acquired immunity in early
childhood.
• The adenoid appears to have an important role in the development of‘immunological memory’ in younger
children.
• Removal of the adenoid in early childhood may be immunologically undesirable.
• Evidence supports the concern that early adenoidectomy produces a detectable negative effect on the
development of serum IgG antibodies, resulting in impaired immunity to pneumococcus.

6. • In children aged 4–10 years, adenotonsillectomy does not
appear to cause significant immune deficiency,although a
slight decrease in IgG, IgA and IgM levels was found in the
post-operative period 4–6 weeks after surgery.
• The evidence that immune status is compromised by
removal of the adenoid alone is inconclusive, as studies
generally include children also having tonsillectomy

7. PATHOLOGICAL EFFECTS
OF THE ADENOID
• The adenoid may be implicated in upper respiratory tract disease due to partial or complete
obstruction of the nasal choanae or as a result of sepsis.
• Pathological manifestation include
Otitis media with effusion.
Recurrent acute otitis media
Rhinosinusitis
Sleep disordered breathing
Olfaction
Neoplasia

8. OTITIS MEDIA WITH EFFUSION
• The benefit of adenoidectomy in the management of otitis media with effusion (OME) has traditionally
been ascribed to the relief of anatomical obstruction of the Eustachian tube.
• It is likely that recurrent acute or chronic inflammation of the adenoid and increased bacterial load,
particularly of Haemophilus influenzae, results in squamous cell metaplasia, reticular epithelium
extension, fibrosis of the interfollicular interconnective tissue and reduced mucociliary clearance in
children with OME compared to those without OME.
• These changes increase bacterial adherence, contributing to the development of a ‘biofilm’ infection
resulting ultimately in middle ear effusion. (A biofilm infection may be defined as ‘a structured
community of bacterial cells enclosed in a self-produced polymeric matrix and adherent to an inert or
living surface)
• Evidence from the MRC TARGET (Trial of Alternative Regimens in Glue Ear Treatment) study supports
consideration of ‘adjuvant’ adenoidectomy in children over the age of 3 who are undergoing insertion of
ventilation tubes (grommets)

9. RECURRENT ACUTE OTITIS MEDIA
• A Cochrane intervention review concluded that adenoidectomy could not be
recommended for the management of acute otitis media.
• Randomized controlled trials of the management of recurrent acute otitis media
have shown adenoidectomy was not effective in reducing episodes of infection in
children younger than 2 years during the follow-up periods of 7–24 months after
surgery.
• It is likely that a partial maturational selective IgA deficiency is a contributing
factor in these ‘otitis-prone’ children.
• Low-dose prophylactic antibiotic treatment is preferred to adenoidectomy in this
group as a means of preventing recurrent acute otitis media and sequelae of
infection until maturation of the immune system occurs naturally.

10. UPPER AIRWAY OBSTRUCTION AND SLEEP DISORDERED
BREATHING
• The prevalence of severe sleep disturbance in children due to upper airway
obstruction is estimated to be approximately 1%, with a peak incidence between 3 and
6 years of age, and an equal sex incidence.
• Airway obstruction due to adenoidal hypertrophy may produce depressed arterial
PaO2 and elevated PaCO2 levels, which return to normal after adenoidectomy.
• The respiratory improvement following adenotonsillectomy also results in a
significant increase in serum insulin- like growth factor-1 (IGF-1),accounting in part
for the frequently observed growth spurt following surgery.

11. • Accumulating evidence suggest that habitual snoring, falling short of obstructive
sleep apnoea may result in neurobehavioural morbidity, poor academic performance
and hyperactive behaviour.
• There is widespread recognition of sleep apnoea in childhood and the acceptance of
the benefits of adenotonsillar surgery in these children, with documented
improvement in respiratory function following adenotonsillectomy.

12. RHINOSINUSITIS
• In childhood, the adenoid is implicated in rhinosinusitis,acting as a reservoir for
pathogenic bacteria.
• In a retrospective study of 48 children with chronic sinusitis undergoing
adenoidectomy or adenotonsillectomy, improvement was reported in the majority
following surgery, and only three children subsequently required functional
endoscopic sinus surgery.
• A prospective study of children with recurrent rhinosinusitis showed that
adenoidectomy was effective in abolishing infective episodes of infection, and that
few children went on to require functional endoscopic sinus surgery

13. OLFACTION
• Adenoidal hyperplasia may reduce olfactory sensitivity and, in particular, retronasal
smell and taste, which improves following adenoidectomy.
• It is,,unlikely that physical obstruction of the airway alone impairs olfaction, and
changes in the olfactory epithelium are a likely factor.
• Where partial or total anosmia is reported, with no evidence of adenoidal
hyperplasia, or failing to resolve after adenoidectomy, further detailed investigation
is required to exclude congenital or hereditary causes for child’s poor or absent sense
of smell.

14. NEOPLASIA
• Unsuspected neoplasia of the adenoid (and tonsils) in childhood is rare.
• Atypical lymphadenopathy,with persistent and asymmetric enlargement of the
tonsils and adenoid, in the absence of infection are suspicious and should prompt
early imaging and biopsy.
• Presentation is often assumed to be due to the more common infective and
obstructive manifestations of adenotonsillar disease so diagnosis is frequently
delayed.

15. ASSESSMENT AND MANAGEMENT
Clinical history
• The history should form part of a full paediatric ENT history with special attention to
symptoms of middle ear disease and nasal obstruction. Specific questions regarding sleep
disturbance, eating and atopic symptoms are important.
• A family history of atopy may be relevant.
• A full history of medication, prescribed, over-the-counter and alternative or
complementary, is important. In children in whom adenoidectomy is being considered, it
is essential to positively exclude a history or family tendency of unusual bleeding or
bruising, as a routine clotting screen may not confirm mild von Willebrand disease.
• In children with Down syndrome, consider potential atlantoaxial instability and cardiac
abnormalities.

16. Clinical examination
• Assessment of the external nose should be made prior to anterior rhinoscopy. In
particular, look for a skin crease in the supratip region that may indicate frequent
nose rubbing from symptoms of rhinitis.
• Simple anterior rhinoscopy in young children may be carried out using a halogen
light otoscope with a large speculum. This is generally better tolerated than
examination with a Thudichum speculum.

17. • Posterior mirror rhinoscopy is not usually possible in children, but many will
tolerate nasal endoscopy using a flexible paediatric endoscope and topical intranasal
local anaesthetic/ vasoconstrictor spray, such as Co-phenylcaine.
• When examining children, topical cocaine must not be used.In children, where
adenoidectomy is the sole surgical procedure indicated, an assessment of the
adenoid should be made prior to the decision to operate.
• Nasal endoscopy is a highly accurate method to assess adenoidal status in an
outpatient setting.When endoscopy is not tolerated, assessment of adenoid size with
lateral soft-tissue radiograph of the nasopharynx is helpful and correlates well with
endoscopic assessment of adenoid size.

19. • In children undergoing another surgical procedure, the adenoid size can be assessed
per-operatively. The adenoid can be classified, based on size and obstruction
• Nasal endoscopy of the nasopharynx to assess adenoid size at the time of surgery is
probably the gold standard, while mirror examination underestimate choanal
occlusion, and palpation is a poor measure of adenoid hypertrophy.
• Where the indication for adenoidectomy is OME rather than obstruction, the size of
the adenoid is not relevant as an indication for removal
• While acoustic rhinomanometry is a useful research tool and MRI provides
extremely accurate volumetric estimation of the adenoid, these investigations are
not applicable in clinical practice.

21. Pre-operative investigations
• Specific investigations for sickle-cell disease, thalassaemia,Down syndrome and
congenital heart disease are indicated as appropriate.
• Management of type 2 diabetes mellitus should follow local paediatric guidelines for
children with diabetes undergoing elective surgery.

22. MEDICAL TREATMENT
FOR THE ADENOID
• Traditionally, surgery and watchful waiting were the only options for symptomatic
adenoid disease.
• There is now a reasonable amount of evidence that topical nasal steroid sprays can
cause reduction in adenoid size with improvements in the presence of middle ear
fluid, audiometric thresholds, nasal obstruction, rhinorrhoea, cough, snoring and
sleep apnoea.
• Topical nasal steroids will probably find a role in clinical practice, although at
present that role is unclear.

23. ADENOIDECTOMY
• Adenoidectomy with or without tonsillectomy and/or insertion of ventilation tubes is one
of the most frequently performed surgical procedures in children.
• In the UK, blind curettage adenoidectomy continues to be the most used technique. Of
these 79.2% use digital palpation and blind curettage, while only 8.1% use suction
coagulation under direct vision.It is surprising that curettage remains so popular, give
the disadvantages of a blind procedure with unpredictable bleeding, poor access to
choanal adenoid and risk of trauma to the Eustachian cushions.
• In contrast, suction diathermy affords direct vision with minimal blood loss,haemostasis
and negligible risk of post-operative haemorrhage.
• Suction diathermy is also effective in performing partial adenoidectomy, leaving a ridge
of adenoidal tissue at the inferior part of the nasopharynx, reducing the risk of
velopharyngeal insufficiency in those children where this is likely after removal of the
adenoid.

24. • Other direct vision techniques include Coblation and microdebrider, which have the
disadvantage of a high unit cost. KTP laser is associated with a high risk of
nasopharyngeal stenosis.
• All single-use instrument techniques have the advantage of abolishing the potential
risk of infection transmission.
• Of the direct-vision techniques,those with the largest clinical experience are the
suction coagulator and the microdebrider. In a randomized controlled trial, the
microdebrider was 20% faster than the curettage technique, but the suction
coagulator is significantly cheaper than the microdebrider.
• Coblation is also suitable for adenoidectomy, with less blood loss and more complete
adenoid removal,but cost limits it application to adenoidectomy as a sole procedure,
while it is not a cost issue when tonsillectomy is performed using the same Coblation
wand.

25. • A meta-analysis of suction coagulation adenoidectomy concluded that there was
reduced intra-operative bleeding,reduced operative time, and a lower overall
complication rate when compared to curette adenoidectomy.
• Where social and geographical factors allow,and with appropriate surgical and
anaesthetic techniques, fluid replacement, antiemetics and analgesia, the majority
of children may be safely discharged home on the same day of surgery.
• Safe discharge home following adenoidectomy using the laryngeal mask airway
within 20 minutes of surgery may be feasible but not preferable.

26. COMPLICATIONS OF ADENOIDECTOMY
Bleeding
• The reactionary haemorrhage rate, i.e. bleeding following adenoidectomy, within 6–20 hours of operation
is reported as less than 0.7%.If bleeding is significant, early return to theatre and postnasal packing for
haemostasis is the usual management.
• Increase in the use of direct-vision techniques and controlled haemostasis at the time of operation will
make reactionary haemorrhage and the need for postnasal packing much less likely.
• Secondary haemorrhage after adenoidectomy is rare.It may be due to bleeding from an aberrant
ascending pharyngeal artery.Unusual reactionary or secondary bleeding should raise the possibility of a
clotting or coagulation defect.
• This requires specialist haematological investigation to confirm or exclude.

27. Dental trauma
• Damage to the teeth during adenoidectomy may be accidental due to slippage of the
gag or supports.
• Great care is needed, particularly if the secondary incisors have erupted: the teeth
are large, but the mandible immature, and it is safer to use an adult gag, which will
rest lateral to the incisors.
• Where there are loose deciduous teeth, consent should be taken pre-operatively to
remove these under anaesthetic to avoid the possibility of inhalation by the child
during the operation or while recovering from anaesthesia.

28. Retained swab
• If swabs are used, it is mandatory to confirm that the count is correct at the end of
the operation before the gag is removed and the anaesthesia reversed. A swab may
be retained either in the nasopharynx or in the laryngopharynx,hidden from the
operator’s view.
• While the early post-operative risk is of airway obstruction by a retained swab, late
presentation months later with infection has also been reported.
• Using direct-vision suction coagulation or Coblation generally abolishes the need for
swabs as haemostasis can be achieved during the procedure.

29. Nasopharyngeal blood clot
• Blood may pool and clot in the nasopharynx during the procedure.
• The nasopharynx should be gently suctioned to clear any clot before removing the
gag.
• Failure to do so may lead to the clot falling onto the larynx during recovery and
causing potentially fatal acute airway obstruction(‘coroner’s clot’).

30. Infection
• Infection in the nasopharynx following adenoidectomy is clinically uncommon,
although many parents report foetor from their child in the week following surgery.
• Foetor is more common following suction adenoidectomy, and it is customary to
prescribe a short course of antibiotics (e.g. azithromycin 10 mg/kg for 3 days post-
operatively)to avoid this.
• Rarely, retropharyngeal and mediastinal abscesses may occur as a result of trauma
and secondary infection of the adenoid bed.

31. Cervical spine
• Non-traumatic atlantoaxial subluxation (Grisel syndrome) is rare, but it is recognized as
a risk associated with adenoidectomy and tonsillectomy.
• Early recognition is crucial in management, and post-operative torticollis should raise
suspicion, leading to radiological investigation.Overuse of diathermy must be avoided,
either for removal of the adenoid or following curettage when used for haemostasis.
Minimum power settings for diathermy should always be used.
• Children with Down syndrome are at increased risk of atlantoaxial subluxation. Current
evidence does not support routine pre-operative plain radiographs in asymptomatic
children with Down syndrome.
• In any event, these are of limited value below the age of 3 years, at which age vertebral
mineralization and epiphyseal development permit accurate radiographic visualization.
Special care of the child’s neck during anaesthesia, surgery and recovery is essential.

32. Velopharyngeal dysfunction
• Severe velopharyngeal incompetence is rare following adenoidectomy, estimated to
occur in between 1 : 1500 and 1 : 10 000 procedures. It may lead to significant
problems with hypernasal speech and swallowing, severe enough to cause nasal
regurgitation of fluids.
• It is mandatory to assess the palate and uvula for submucous cleft of the palate
prior to surgery as adenoidectomy may unmask pre-existing palatal dysfunction.
• Bifid uvula can be a marker of a submucous cleft, present in 59% of cases.Using a
direct-vision technique, it is possible to perform a partial adenoidectomy, clearing
the choanal airway and superior nasopharynx, but leaving a rim of adenoid intact at
the velopharyngeal junction, avoiding velopharyngeal insufficiency.
• Reconstructive surgery to correct hypernasal speech may be required if speech and
swallowing are severely affected.

33. Regrowth of the adenoid
• A cross-sectional follow-up study of children after curettage adenoidectomy, 2–5
years after surgery concluded that 71% had no residual obstructing adenoid.
• However, the criterion for adenoid sufficient to cause nasal obstruction was tissue
occupying more than 40% of the nasopharynx.
• In a retrospective study of 3231 children,1.6% required reoperation for recurrence of
their symptoms following curettage adenoidectomy.
• Direct vision techniques are likely to minimize residual adenoid tissue and possible
‘regrowth’

34. Death
• Expert reports from malpractice cases are the usual source of such data. Of 32
deaths related to bleeding following adenoidectomy and tonsillectomy, one followed
direct vascular injury during adenoidectomy.
• Two deaths clearly followed infection secondary to aspiration of adenoid tissue.
While not defined as adenoidectomy alone, four deaths were due to medication
errors, route, dose or drug.Following surgery in younger children with sleep-
disordered breathing, special care should be exercised when prescribing opioid
analgesics for both per-operative and discharge analgesia.
• In those who are ultra-rapid metabolizers of codeine, toxic doses of morphine can
develop fatal respiratory failure.

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