Chapter 66 Current techniques of adenoidectomy
The clinical significance of adenoid hypertrophy was not truly appreciated until the mid-19th century. This was due to their relatively inaccessible location given the technology available at that time. Once discovered, various techniques for the removal of the adenoids were developed. Some of these basic techniques have remained with us since that time.
Children with signs and symptoms of obstructive sleep apnea, or those with polysomnogram-proven disease, should have their adenoids evaluated as part of a routine work-up. This can be done in a number of ways. In children of just about any age, flexible fiberoptic nasopharyngoscopy provides the most direct means of evaluation. A camera and monitor attached to the scope can provide families with visual reinforcement. Alternatively, a lateral plain film of the nasopharynx can demonstrate adenoid hypertrophy and resultant compromise of the nasal air column. Although not routinely obtained to evaluate for adenoid hypertrophy, CT scans and MRIs can also demonstrate enlargement of the adenoid pad.
Adenoidectomy is usually inappropriate in children with a history of cleft palate, overt or submucous, or those with a history of velopharyngeal insufficiency. A balance between relief of obstruction and the creation of velar incompetence is crucial. Families must be counseled as to the increased risk for this important complication, even if a limited procedure is performed.
Various options for airway management exist and it is important for the surgical and anesthesia teams to decide on this before the procedure begins. A straight endotracheal tube, laryngeal mask airway (LMA) or oral RAE tube (Ring–Adair–Elwyn) may be used. The surgeon must consider factors such as other procedures (i.e. tonsillectomy) being performed when deciding on the type of airway management.
Historically, adenoidectomy was performed with the surgeon facing the patient, who was sitting upright. Some surgeons still currently employ an orientation similar to that of endoscopic sinus surgery. Today, the Rose position is commonly used in which the patient’s head and neck are extended and the surgeon sits behind the patient. The eyes are protected and the patient is sterilely draped. A mouth gag, such as the Crowe–Davis or McGyver, is then carefully inserted into the mouth and the oropharynx is exposed. The mouth gag can be suspended per surgeon preference. The soft palate should then be visually inspected and palpated to ensure that a submucous cleft is not present. Visualization of the nasopharynx can be easily achieved using a defogged #5 laryngeal mirror and a headlight. Exposure can be enhanced using either one or two red rubber catheters. These are placed transnasally, retrieved from the oropharynx and then clamped back on themselves, effectively retracting the soft palate.
The use of a curette to remove the adenoids dates back to some of the earliest attempts at this procedure and remains an incredibly popular technique worldwide. The original design of Jacob Gottenstein has been modified and many different lengths, widths and curvatures are available. The basic principle is that of a sharp horizontal knife-edge that is designed to cut through the base of the adenoid bed. The instrument is designed to follow the natural curvature of the nasopharyngeal skull base (Fig. 66.1).
The curette may be passed blindly into the nasopharynx, or the laryngeal mirrors may be used to guide the cutting edge into position. Visualization of the fossa of Rosenmuller helps guide appropriate curette size. The curette is placed against the vomer and then pushed through the adenoid tissue to the more resistant deeper layers. The handle is pulled toward the head and the surgeon’s other hand acts as a fulcrum at approximately the level of the incisors. The curette is swept in an arc through the adenoid tissue until the level of Passavant’s ridge, which is the inferior aspect of the dissection. After the initial pass, the adenoid bed is inspected for the completeness of the procedure. If there is residual adenoid tissue left behind, it must be removed using either a smaller curette or St Claire-Thompson forceps. A tonsil sponge is then generally placed into the nasopharynx to aid in hemostasis. These sponges may contain medications such as oxymetazoline or can be used alone. It is our preference to finalize hemostasis using a suction monopolar cautery using mirror guidance although other techniques including pressure packing, bismuth subgallate and silver nitrate have been described. Once final hemostasis is achieved, the nasopharynx and oropharynx should be irrigated and the stomach emptied of its contents prior to extubation.
The widespread use of the suction monopolar cautery unit to achieve hemostasis after adenoidectomy naturally led to its use as a primary means of reducing adenoid tissue. With the patient in the Rose position, as described above, the adenoid pad is viewed with a mirror. The monopolar cautery unit, generally set at 30–40 watts, can then be shaped to fit the patient’s unique anatomy. Starting at the choana and working inferiorly, the adenoids are sequentially ablated using the cautery unit (Fig. 66.2). As the tissue fluid is vaporized there is dramatic reduction in the size of the adenoid tissue. Care is taken to avoid inadvertent cautery of non-adenoidal tissue. Bleeding tends to be minimal using this technique and can be controlled with any of the methods described above.
Fig. 66.2 Ablation adenoidectomy. Under mirror visualization the adenoid pad is ablated using the suction monopolar cautery. Note ability to adequately view the choana and Eustachian tube region with this technique to avoid inadvertent injury to these structures.
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