- Email: [email protected]
Current techniques of adenoidectomy
CURRENT TECHNIQUES OF ADENOIDECTOMY CHRISTOPHER M. D l S C O L O , M D , A B B A S P E T E R J. K O L T A I , M D , F A C S , F A A P
A. Y O U N E S ,
MD,
The presence of the adenoids remained undiscovered until the mid 1800s. Today, adenoidal pathology is recognized as a very common cause of morbidity in children. Surgical removal of the adenoids remains one of the most common procedures performed within our specialty. The location of the adenoids within the nasopharynx has led to the development of many instruments and techniques to facilitate their removal. All are premised on the adequate removal of the adenoidal tissue without damage to surrounding structures. The authors present a review of traditional and more recent approaches to adenoidectomy.
It is surprising that despite the long and rich history of otolaryngology, the discovery of the clinical significance of the adenoids was not made until the mid 1800s. We now understand that enlargement and infection of the adenoids contributes to problems of otitis media, sinusitis, obstructive sleep-disordered breathing, and alterations of facial growth. As a consequence, adenoidectomy has become one of the most frequently performed surgeries within our specialty. The adenoids remained unrecognized because of their inaccessible location and the fact that most adenoidal pathology occurred in young children. Although Yearsley 1 suspected the presence of the adenoids in 1842 when he wrote that there was "an overlapping of the mouths of the Eustachian tube by loose mucous membranes," the original insight that adenoids caused disease was made by Hans Willhelm Meyer and published in 1868.1 In the classic paper "On Adenoid Vegetation in the Nasopharyngeal Cavity," he accurately described adenoidal hypertrophy based not on sight but on palpation, and recommended their removal with a sharp ring curette manipulated transorally) Soon after, many new and creative means were developed for the removal of adenoids, most of which approached the adenoids transorally. These included a nail curette, which is essentially a steel scraper worn on the index finger, a variety of punches, and the adenotome. The instrument that has best stood the test of time, the adenoid curette, was introduced by Jacob Gottenstein in 1885.1
recurrent sinus disease. Obstructive indications include adenoidal hypertrophy associated with hyponasal speech, snoring, chronic mouth breathing, and obstructive sleep apnea. It is interesting to note that the original observations that obstructive apnea can cause cor pulmonale was made in young children in w h o m the cause of obstruction was the adenoids. Some children with adenoidal enlargement will have abnormalities in craniofacial development. 2
ANESTHESIA Adenoidectomies were performed blindly without anesthesia until well into the early part of the 20th century. However, as surgeons sought visualization for greater precision, as well as better airway protection, anesthesia became a necessity and is now accepted as part of the standard of care. The problems of sharing the airway for both control and access were overcome nearly 100 years ago with endotracheal intubation and the use of oral retractors. Traditional endotracheal tubes, although safe and effective, can be kinked and obstructed b y the gag apparatus. 3 Precurved and reinforced endotracheal tubes, such as the RAE tube, minimize this problem. Some have advocated the use of a laryngeal mask airway (LMA) for adenoidectomy anesthesia. 4
ADENOIDECTOMY TECHNIQUES INDICATIONS FOR ADENOIDECTOMY Removal of the adenoids is indicated when they are chronically infected or causing obstruction, and the two are commonly related. Infectious indications include recurrent adenoiditis, which is defined as 4 or more episodes per year despite appropriate medical therapy, recurrent otitis media associated with adenoidal hypertrophy, and From the Section of Pediatric Otolaryngology, Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Peter J. Koltai, MD, FACS, FAAP, Section of Pediatric Otolaryngology, Cleveland Clinic Foundation, 9500 Euclid Ave.-A71, Cleveland, OH 44195. Copyright © 2001 by W.B. Saunders Company 1043-1810/01/1204-0005535.00/0 doi: 10.1053/otot.2001.29187
Since the earliest descriptions of adenoidectomy, numerous techniques have been described and used successfully. All techniques are based on the principle of adequate removal of the adenoids without damage to the surrounding structures, such as the torus tubarus, the palate, the posterior pharyngeal wall, and the choana. Recent minimally invasive and endoscopic technologies have also been applied for adenoidectomy.
POSITIONING AND PREPARING FOR SURGERY Adenoidectomy was originally performed b y the surgeon facing the patient, who was sitting up. A contemporary version of this approach is still used by some surgeons, with the operator sitting in the same orientation to the patient as during endoscopic sinus surgery. The palate is
OPERATIVETECHNIQUESIN OTOLARYNGOLOGY--HEADAND NECK SURGERY,VOL 12, NO 4 (DEC),2001: PP 199-203
1 99
elevated for a direct view of the nasopharynx, and the adenoid is removed either with a curette or an adenotome. Today, most surgeons use the Rose position, where the surgeon sits behind the patient, who has the head and neck extended. This is enhanced by a sheet roll under the shoulder and a towel ring under the occiput, which tends to advance the adenoid bed anteriorly, facilitating its removal, but also potentiating possible injury to the nasopharyngeal muscles. The eyes are taped shut and the patient's head and body are sterilely draped. Once the patient is appropriately positioned and covered, the lower jaw is retracted with a groove-bladed mouth gag, such as the Crowe-Davis or McGyver gag, which is then suspended from a bedside Mayo stand. To minimize the problem of postoperative velopharyngeal insufficiency caused b y an adenoidectomy being performed in a child with palatal abnormality, the soft palate must be visually and digitally inspected. Visualization of the nasopharynx is best accomplished indirectly with a defogged #5 laryngeal mirror. It is further enhanced with the use of 2 #6 French soft rubber catheters passed transnasally into the mouth, which are then clamped back on themselves extraorally, effectively retracting the soft palate. Illumination is achieved with a headlight. CURETTE
ADENOIDECTOMY
Curette adenoidectomy, which dates back to the earliest attempts at the procedure, is the most widely used technique worldwide. A selection of curette widths, lengths, and curvatures are available, all based on Jacob Gottenstein's original design) They all have in common a sharp horizontal knife-edge for cutting through the base of the adenoid bed. The curvature of the side arms that carry the blade and form the vertical posts of the window through which the adenoid tissue passes are intended to follow the curved topography of the nasopharyngeal skull base. The vertical posts converge into the handle, which is about 20 cm long with a grip at the end, the function of which is to apply the necessary pressure to safely pass the knife through the tissues. The operation was originally performed with digital palpation, and some surgeons still practice this art; however, most prefer visualizing the placement of the curette. With the child in the Rose position and the jaw and palate retracted, the mirror is placed against the bottom of the tongue blade. The full adenoid bed is scanned, and the torus tubarus, the fossa of Rosenmuller, and the vomer are identified. The curette size is selected based on the distance between the 2 fossa of Rosenmuller and is placed up against the vomer, then pushed through the spongy adenoid tissue to the more surgically resistant layer of the underlying muscles. The handle is pulled back toward the head, with the thumb from the other hand used as a fulcrum at the level of the upper incisors. The movement of the handle sweeps the knife blade in an arc through the base of the adenoids, terminating with their removal at the level of Passavant's ridge. After the first pass, the site is revisualized; if residual tissues remain, they are removed with appropriately selected curette sizes and shapes, specific to the remaining tissues. The need for this is often caused by dull curette knife and is one of the main drawbacks of the curette technique. The frustration of a dull curette blade is contrasted with a sharp curette's potential for digging inadvertently into the deeper nasopharyngeal musculature, especially when wielded by inexpert hands. After completion of tissue removal, a tonsil sponge is temporarily placed into the nasopharynx for hemostasis. 200
While this is in place, the tonsillectomy can be performed at this time if both procedures are being performed. For hemostasis, we prefer using a suction coagulator under direct visualization via a mirror, although other techniques, such as pressure packing, silver nitrate cautery, and bismuth subgallate application, have also been used. ADENOTOME
The adenotome is another early instrument that remains in use for adenoidectomy. It is a basket- like device with a curved, open face, into which the adenoid tissue fits before being sliced off by the flexible steel blade that is the lid to the basket. The rounded geometry of the opening fits well into the shape of a nasopharynx, and various widths and lengths of adenotome are available. The adenotome is best placed under direct vision, elevating the velum with a palatal retractor, and with the surgeon sitting by the side of the patient. The instrument is firmly pressed into the midline of the adenoid bed against the posterior pharyngeal wall. It is then rotated downward as the blade is closed. Residual tissue laterally can be removed with curved St. Claire-Thompson nasopharyngeal forceps (Fig 1). LASER ADENOIDECTOMY
There is scant literature on the topic of laser adenoidectomy. Dr. Daniel Akin has taught an instructional course at the Annual Meeting of the American Academy of Otolaryngology--Head and Neck Surgery on a technique of laser tonsillectomy and adenoidectomy, s The operation is performed with a CO 2 laser attached to the microslad on a surgical microscope, positioned at the head of the table, above the patient. The lips and teeth are first covered with foil and the rest of the face with wet towels after the jaw and the palate have been retracted. Working with a joystick on the microscope, the laser light is reflected into the nasopharynx with a polished metal mirror, which also allows view of the ablation. 5 The smoke plume is evacu-
FIGURE 1. The adenotome placed in the nasopharyngeal area with adenoid tissue fitted into the curved open face before being sliced off by its flexible steel blade, which is firmly pressed into the midline of the adenoid bed against the posterior pharyngeal wall. CURRENT TECHNIQUES OF ADENOIDECTOMY
FIGURE 2. A modified Crowe-Davis type oral gag retracts the lower jaw while the patient is retracted with catheters, allowing greater access to the nasopharynx with the shaver under indirect visualization with a mirror.
ated via a Yankhauer-type sucker kept in the oral cavity by an assistant. Acquired nasopharyngeal stenosis has been reported in children after KTP laser adenoidectomy. 6 ABLATION
ADENOIDECTOMY
The use of the laryngeal mirror with suction cautery to achieve hemostasis after more traditional methods of adenoidectomy has led to the development of ablative adenoidectomy. Several well-done studies have shown the utility, efficacy, and safety of this technique. 7-9 When compared with curettage, ablative techniques are more precise, faster, and result in less blood loss. 1° As with curette adenoidectomy, the procedure is done in the Rose position. A malleable suction cautery is curved to the appropriate arc and introduced into the nasopharynx. Under direct vision, the adenoids are ablated, starting at the
FIGURE 3. The adenoids are removed in a side-to-side fashion, starting superiorly in the region of the choanal sill and progressing inferiorly, keeping the oscillating blade in view at all times. DISCOLO, YOUNES, AND KOLTAI
FIGURE 4. The adenoids are removed in a side-to-side fashion, starting superiorly in the region of the choanal sill and pregressing inferiorly, keeping the oscillating blade in view at all times.
choanae and progressing inferiorly. Typically, the cautery is set between 30 and 40 W. When energy is applied, the adenoid tissue first turns white then shrinks to a char as the tissue fluid is vaporized. The adenoids seem particularly suited for evaporation with this method because of their soft architecture. Any bleeding can be controlled with the same suction cautery, and nasopharyngeal packing is usually not required. Care is taken to avoid cautery of any nonadenoidal tissues. ENDOSCOPIC
ADENOIDECTOMY
The application of endoscopic technology with telescopes for visualizing adenoidectomy via a transnasal approach has been described. Cannon et al described vasoconstricting the nose and adenoid bed topically, then removing the adenoids with punch type sinus forceps. 11 Becker et al used straight or 45 ° Blakeslee forceps transnasally, or 90 °
FIGURE 5. After completion of the adenoidectomy and packing the nasopharynx for several minutes, any residual bleeding is controlled with suction cautery.
201
Blakeslee forceps placed transorally, for performing endoscopic adenoidectomy,la The authors noted that occasional out fracture of the inferior turbinates or septoplasty had to be performed to gain adequate access to the nasopharynx. Advantages of this technique include precise removal of the tissue immediately adjacent to the Eustachian tube and possibility of resection under local anesthesia in selected patients. In our hands, it seems to be a hard way to perform an easy operation.
POWER-ASSISTED ADENOIDECTOMY Powered instruments for endoscopic sinus surgery were introduced in 1993 by Dr. Rueben Setliff.13 Subsequently, Parsons described powered instruments for nasal disease in children, including transnasal adenoidectomy.14 Koltai et al introduced transoral power-assisted adenoidectomy.15
TRANSNASAL ADENOIDECTOMY
equally low complication rate. The main disadvantage is the increased cost of the shaver blade. 15'17
PARTIAL A D E N O I D E C T O M Y Adenoidectomy in the face of developmental palatal abnormalities, such as submucous cleft, can lead to velopharyngeal insufficiency and hypernasal speech, yet children with these palatal problems may still require adenoidectomy. In the past, only the lateral portion of the adenoids were removed in these patients; however, results from this technique have not withstood the test of time. Today, partial adenoidectomy involves removing the superior two thirds of the adenoid pad, leaving sufficient adenoid tissue to prevent velopharyngeal insufficiency.18 The St. Clair-Thompson forceps, the endoscopic shaver, and the suction cautery are all effective tools for this purpose, but require careful visualization to preserve a buttress of adenoid tissue for velar closure.
Powered Transnasal Adenoidectomy
CONCLUSION
This procedure, which is advocated by Dr. Eji Yanagisawa, requires an endoscopic sinus surgery set and is not recommended for routine cases. 16 It should be reserved for superiorly situated adenoids that project into the nasal cavity or for when choanal obstruction persists that cannot be removed at the conclusion of standard transoral surgery. 16 The patient is positioned as for endoscopic sinus surgery. The nasal cavity is decongested with topical medication. If added exposure is needed, the inferior turbinates can be out fractured. A zero degree telescope is used to visualize the adenoids and the microdebrider is placed in either the ipsilateral or contralateral nostril. The adenoidal tissue is then removed under direct visualization. Occasionally, the inferior aspect of the adenoid bed cannot be removed via transnasal approach and the operation is then completed transorally. An advantage of this technique is the neutral position that the head and neck are maintained in. This is important in patients with cervical instability such as in children with Down syndrome.
Diseases of the adenoids cause a variety of upper respiratory tract symptoms in children, and an adenoidectomy has been shown to be an effective way to treat these problems. As a result, adenoidectomy is one of the most common procedures performed in children. There are many ways to perform an adenoidectomy effectively. The most commonly used tools today are the curette, the suction cautery, and the endoscopic shaver. What is common to all contemporary techniques is that visualization and surgical control of bleeding have become the accepted standard of care.
Powered Transoral Adenoidectomy Initially described in 1997, the transoral approach makes use of a bent endoscopic shaver blade and mirror visualization. The patient is placed in the Rose position. A modified Crowe-Davis type oral gag (designed by Dr. Max April and allows greater access to the nasopharynx with the shaver), is used to retract the lower jaw while the palate is retracted with catheters. Various shaver manufacturers make either prebent or bendable blades that allow the instrument access to the nasopharynx under indirect visualization with a mirror (Fig 2). Starting superiorly in the region of the choanal sill, the adenoids are removed in a side-to-side fashion, progressing inferiorly. Tissue is removed only at the site of the oscillating blade, which is kept in view at all times (Figs 3 and 4). By angling the blade, tissue immediately adjacent to the Eustachian tube can be easily and safely removed. The depth of the resection is also readily monitored. Once completed, a tonsil pack is placed in the nasopharynx for several minutes, and then any residual bleeding is controlled with suction cautery (Fig 5). When compared with the curette technique, this method was found to be significantly faster, resulted in less blood loss, and had an
202
ACKNOWLEDGEMENT We appreciate the assistance of Mr. Scott Beam in the preparation of this manuscript.
REFERENCES 1. Weir N: Otolaryngology--AnIllustrated History. Boston, MA, Butterworths, 1990 2. WiatrakBJ, WoolleyAL: Pharyngitisand adenotonsillardisease, in CummingsCW (ed): OtolaryngologyHead and Neck Surgery,vol 5 (ed 3). St. Louis,MO, Mosby-YearBook, 1998, pp 88-215 3. Sen AK, Gupta B: Herniationof RAE tube through split Boyle-Davis gag. Anesth Intens Care 18:577-578, 1990 4. WilliamsPJ, BaileyPM: Comparisonof the reinforcedlaryngealmask airway and tracheal intubationfor adenotonsillectomy.Br J Anesth 70:30-33, 1993 5. Martinez SA, Akin DP: Laser tonsillectomyand adenoidectomy. OtolaryngolClin North Am 20:371-376, 1987 6. GiannoniC, SulekM, FriedmanEM, et al: Acquirednasopharyngeal stenosis: A warning and review. Arch OtolaryngolHead Neck Surg 124:163-167, 1998 7. Sherman G: Innovative surgical procedure for adenoidectomy.Laryngoscope 92:700-701, 1982 8. ClemensJ, McMurrayJS, WillgingJP: Electrocauteryversus curette adenoidectomy:Comparison of postoperative results. Int J Pediatr Otorhinolaryngol43:115-122, 1998 9. Hartley BEJ, Papsin BC, Albert DM: Suction diathermyadenoidectomy. Clin Otolaryngol23:308-309, 1998 10. Wright ED, ManoukianJJ, Shapiro RS: Ablative adenoidectomy:A new techniqueusing simultaneousliquefaction/aspiration.J Otolaryngol 26:36-43, 1997 11. CannonCR,ReplogleWH, SchenkMP: Endoscopic-assistedadenoidectomy. OtolaryngolHead Neck Surg 121:740-744, 1999 CURRENTTECHNIQUESOF ADENOIDECTOMY
12. Becker SP, Roberts N, Coglianese D: Endoscopic adenoidectomy for relief of serous otitis media. Laryngoscope 102:1379-1384, 1992 13. Setliff RC, Parsons DS: The hummer. New instrumentation for endoscopic sinus surgery. Am J Rhinol 8:275-278, 1994 14. Parsons DS: Rhinologic uses of powered instrumentation in children beyond sinus surgery. Otolaryngol Clin North Am 29:105-114, 1996 15. Koltai PJ, Kalathia AS, Stanislaw P: Power assisted adenoidectomy. Arch Otolaryngol Head Neck Surg 123:685-688, 1997
DISCOLO, YOUNES,AND KOLTAI
16. Yanagisawa E, Ho SY, Mirante JP: Powered transnasal adenoidectomy, in Yanagisawa E, Christmas DA, Mirante JP (eds): Powered Instrumentation in Otolaryngology Head and Neck Surgery, Canada, Thomson Learning, 2001, p. 247 17. Heras H, Koltai PJ: Safety of powered instrumentation for adenoidectomy. Int J Pediatr Ot0rhinolaryngol 44:149-153, 1998 18. Masters FW, Bingham HG, Robinson DW: The prevention and treatment of hearing loss in the cleft palate child. Plast Reconstr Surg 25:503-509, 1960
20~
A. Y O U N E S ,
MD,
The presence of the adenoids remained undiscovered until the mid 1800s. Today, adenoidal pathology is recognized as a very common cause of morbidity in children. Surgical removal of the adenoids remains one of the most common procedures performed within our specialty. The location of the adenoids within the nasopharynx has led to the development of many instruments and techniques to facilitate their removal. All are premised on the adequate removal of the adenoidal tissue without damage to surrounding structures. The authors present a review of traditional and more recent approaches to adenoidectomy.
It is surprising that despite the long and rich history of otolaryngology, the discovery of the clinical significance of the adenoids was not made until the mid 1800s. We now understand that enlargement and infection of the adenoids contributes to problems of otitis media, sinusitis, obstructive sleep-disordered breathing, and alterations of facial growth. As a consequence, adenoidectomy has become one of the most frequently performed surgeries within our specialty. The adenoids remained unrecognized because of their inaccessible location and the fact that most adenoidal pathology occurred in young children. Although Yearsley 1 suspected the presence of the adenoids in 1842 when he wrote that there was "an overlapping of the mouths of the Eustachian tube by loose mucous membranes," the original insight that adenoids caused disease was made by Hans Willhelm Meyer and published in 1868.1 In the classic paper "On Adenoid Vegetation in the Nasopharyngeal Cavity," he accurately described adenoidal hypertrophy based not on sight but on palpation, and recommended their removal with a sharp ring curette manipulated transorally) Soon after, many new and creative means were developed for the removal of adenoids, most of which approached the adenoids transorally. These included a nail curette, which is essentially a steel scraper worn on the index finger, a variety of punches, and the adenotome. The instrument that has best stood the test of time, the adenoid curette, was introduced by Jacob Gottenstein in 1885.1
recurrent sinus disease. Obstructive indications include adenoidal hypertrophy associated with hyponasal speech, snoring, chronic mouth breathing, and obstructive sleep apnea. It is interesting to note that the original observations that obstructive apnea can cause cor pulmonale was made in young children in w h o m the cause of obstruction was the adenoids. Some children with adenoidal enlargement will have abnormalities in craniofacial development. 2
ANESTHESIA Adenoidectomies were performed blindly without anesthesia until well into the early part of the 20th century. However, as surgeons sought visualization for greater precision, as well as better airway protection, anesthesia became a necessity and is now accepted as part of the standard of care. The problems of sharing the airway for both control and access were overcome nearly 100 years ago with endotracheal intubation and the use of oral retractors. Traditional endotracheal tubes, although safe and effective, can be kinked and obstructed b y the gag apparatus. 3 Precurved and reinforced endotracheal tubes, such as the RAE tube, minimize this problem. Some have advocated the use of a laryngeal mask airway (LMA) for adenoidectomy anesthesia. 4
ADENOIDECTOMY TECHNIQUES INDICATIONS FOR ADENOIDECTOMY Removal of the adenoids is indicated when they are chronically infected or causing obstruction, and the two are commonly related. Infectious indications include recurrent adenoiditis, which is defined as 4 or more episodes per year despite appropriate medical therapy, recurrent otitis media associated with adenoidal hypertrophy, and From the Section of Pediatric Otolaryngology, Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Peter J. Koltai, MD, FACS, FAAP, Section of Pediatric Otolaryngology, Cleveland Clinic Foundation, 9500 Euclid Ave.-A71, Cleveland, OH 44195. Copyright © 2001 by W.B. Saunders Company 1043-1810/01/1204-0005535.00/0 doi: 10.1053/otot.2001.29187
Since the earliest descriptions of adenoidectomy, numerous techniques have been described and used successfully. All techniques are based on the principle of adequate removal of the adenoids without damage to the surrounding structures, such as the torus tubarus, the palate, the posterior pharyngeal wall, and the choana. Recent minimally invasive and endoscopic technologies have also been applied for adenoidectomy.
POSITIONING AND PREPARING FOR SURGERY Adenoidectomy was originally performed b y the surgeon facing the patient, who was sitting up. A contemporary version of this approach is still used by some surgeons, with the operator sitting in the same orientation to the patient as during endoscopic sinus surgery. The palate is
OPERATIVETECHNIQUESIN OTOLARYNGOLOGY--HEADAND NECK SURGERY,VOL 12, NO 4 (DEC),2001: PP 199-203
1 99
elevated for a direct view of the nasopharynx, and the adenoid is removed either with a curette or an adenotome. Today, most surgeons use the Rose position, where the surgeon sits behind the patient, who has the head and neck extended. This is enhanced by a sheet roll under the shoulder and a towel ring under the occiput, which tends to advance the adenoid bed anteriorly, facilitating its removal, but also potentiating possible injury to the nasopharyngeal muscles. The eyes are taped shut and the patient's head and body are sterilely draped. Once the patient is appropriately positioned and covered, the lower jaw is retracted with a groove-bladed mouth gag, such as the Crowe-Davis or McGyver gag, which is then suspended from a bedside Mayo stand. To minimize the problem of postoperative velopharyngeal insufficiency caused b y an adenoidectomy being performed in a child with palatal abnormality, the soft palate must be visually and digitally inspected. Visualization of the nasopharynx is best accomplished indirectly with a defogged #5 laryngeal mirror. It is further enhanced with the use of 2 #6 French soft rubber catheters passed transnasally into the mouth, which are then clamped back on themselves extraorally, effectively retracting the soft palate. Illumination is achieved with a headlight. CURETTE
ADENOIDECTOMY
Curette adenoidectomy, which dates back to the earliest attempts at the procedure, is the most widely used technique worldwide. A selection of curette widths, lengths, and curvatures are available, all based on Jacob Gottenstein's original design) They all have in common a sharp horizontal knife-edge for cutting through the base of the adenoid bed. The curvature of the side arms that carry the blade and form the vertical posts of the window through which the adenoid tissue passes are intended to follow the curved topography of the nasopharyngeal skull base. The vertical posts converge into the handle, which is about 20 cm long with a grip at the end, the function of which is to apply the necessary pressure to safely pass the knife through the tissues. The operation was originally performed with digital palpation, and some surgeons still practice this art; however, most prefer visualizing the placement of the curette. With the child in the Rose position and the jaw and palate retracted, the mirror is placed against the bottom of the tongue blade. The full adenoid bed is scanned, and the torus tubarus, the fossa of Rosenmuller, and the vomer are identified. The curette size is selected based on the distance between the 2 fossa of Rosenmuller and is placed up against the vomer, then pushed through the spongy adenoid tissue to the more surgically resistant layer of the underlying muscles. The handle is pulled back toward the head, with the thumb from the other hand used as a fulcrum at the level of the upper incisors. The movement of the handle sweeps the knife blade in an arc through the base of the adenoids, terminating with their removal at the level of Passavant's ridge. After the first pass, the site is revisualized; if residual tissues remain, they are removed with appropriately selected curette sizes and shapes, specific to the remaining tissues. The need for this is often caused by dull curette knife and is one of the main drawbacks of the curette technique. The frustration of a dull curette blade is contrasted with a sharp curette's potential for digging inadvertently into the deeper nasopharyngeal musculature, especially when wielded by inexpert hands. After completion of tissue removal, a tonsil sponge is temporarily placed into the nasopharynx for hemostasis. 200
While this is in place, the tonsillectomy can be performed at this time if both procedures are being performed. For hemostasis, we prefer using a suction coagulator under direct visualization via a mirror, although other techniques, such as pressure packing, silver nitrate cautery, and bismuth subgallate application, have also been used. ADENOTOME
The adenotome is another early instrument that remains in use for adenoidectomy. It is a basket- like device with a curved, open face, into which the adenoid tissue fits before being sliced off by the flexible steel blade that is the lid to the basket. The rounded geometry of the opening fits well into the shape of a nasopharynx, and various widths and lengths of adenotome are available. The adenotome is best placed under direct vision, elevating the velum with a palatal retractor, and with the surgeon sitting by the side of the patient. The instrument is firmly pressed into the midline of the adenoid bed against the posterior pharyngeal wall. It is then rotated downward as the blade is closed. Residual tissue laterally can be removed with curved St. Claire-Thompson nasopharyngeal forceps (Fig 1). LASER ADENOIDECTOMY
There is scant literature on the topic of laser adenoidectomy. Dr. Daniel Akin has taught an instructional course at the Annual Meeting of the American Academy of Otolaryngology--Head and Neck Surgery on a technique of laser tonsillectomy and adenoidectomy, s The operation is performed with a CO 2 laser attached to the microslad on a surgical microscope, positioned at the head of the table, above the patient. The lips and teeth are first covered with foil and the rest of the face with wet towels after the jaw and the palate have been retracted. Working with a joystick on the microscope, the laser light is reflected into the nasopharynx with a polished metal mirror, which also allows view of the ablation. 5 The smoke plume is evacu-
FIGURE 1. The adenotome placed in the nasopharyngeal area with adenoid tissue fitted into the curved open face before being sliced off by its flexible steel blade, which is firmly pressed into the midline of the adenoid bed against the posterior pharyngeal wall. CURRENT TECHNIQUES OF ADENOIDECTOMY
FIGURE 2. A modified Crowe-Davis type oral gag retracts the lower jaw while the patient is retracted with catheters, allowing greater access to the nasopharynx with the shaver under indirect visualization with a mirror.
ated via a Yankhauer-type sucker kept in the oral cavity by an assistant. Acquired nasopharyngeal stenosis has been reported in children after KTP laser adenoidectomy. 6 ABLATION
ADENOIDECTOMY
The use of the laryngeal mirror with suction cautery to achieve hemostasis after more traditional methods of adenoidectomy has led to the development of ablative adenoidectomy. Several well-done studies have shown the utility, efficacy, and safety of this technique. 7-9 When compared with curettage, ablative techniques are more precise, faster, and result in less blood loss. 1° As with curette adenoidectomy, the procedure is done in the Rose position. A malleable suction cautery is curved to the appropriate arc and introduced into the nasopharynx. Under direct vision, the adenoids are ablated, starting at the
FIGURE 3. The adenoids are removed in a side-to-side fashion, starting superiorly in the region of the choanal sill and progressing inferiorly, keeping the oscillating blade in view at all times. DISCOLO, YOUNES, AND KOLTAI
FIGURE 4. The adenoids are removed in a side-to-side fashion, starting superiorly in the region of the choanal sill and pregressing inferiorly, keeping the oscillating blade in view at all times.
choanae and progressing inferiorly. Typically, the cautery is set between 30 and 40 W. When energy is applied, the adenoid tissue first turns white then shrinks to a char as the tissue fluid is vaporized. The adenoids seem particularly suited for evaporation with this method because of their soft architecture. Any bleeding can be controlled with the same suction cautery, and nasopharyngeal packing is usually not required. Care is taken to avoid cautery of any nonadenoidal tissues. ENDOSCOPIC
ADENOIDECTOMY
The application of endoscopic technology with telescopes for visualizing adenoidectomy via a transnasal approach has been described. Cannon et al described vasoconstricting the nose and adenoid bed topically, then removing the adenoids with punch type sinus forceps. 11 Becker et al used straight or 45 ° Blakeslee forceps transnasally, or 90 °
FIGURE 5. After completion of the adenoidectomy and packing the nasopharynx for several minutes, any residual bleeding is controlled with suction cautery.
201
Blakeslee forceps placed transorally, for performing endoscopic adenoidectomy,la The authors noted that occasional out fracture of the inferior turbinates or septoplasty had to be performed to gain adequate access to the nasopharynx. Advantages of this technique include precise removal of the tissue immediately adjacent to the Eustachian tube and possibility of resection under local anesthesia in selected patients. In our hands, it seems to be a hard way to perform an easy operation.
POWER-ASSISTED ADENOIDECTOMY Powered instruments for endoscopic sinus surgery were introduced in 1993 by Dr. Rueben Setliff.13 Subsequently, Parsons described powered instruments for nasal disease in children, including transnasal adenoidectomy.14 Koltai et al introduced transoral power-assisted adenoidectomy.15
TRANSNASAL ADENOIDECTOMY
equally low complication rate. The main disadvantage is the increased cost of the shaver blade. 15'17
PARTIAL A D E N O I D E C T O M Y Adenoidectomy in the face of developmental palatal abnormalities, such as submucous cleft, can lead to velopharyngeal insufficiency and hypernasal speech, yet children with these palatal problems may still require adenoidectomy. In the past, only the lateral portion of the adenoids were removed in these patients; however, results from this technique have not withstood the test of time. Today, partial adenoidectomy involves removing the superior two thirds of the adenoid pad, leaving sufficient adenoid tissue to prevent velopharyngeal insufficiency.18 The St. Clair-Thompson forceps, the endoscopic shaver, and the suction cautery are all effective tools for this purpose, but require careful visualization to preserve a buttress of adenoid tissue for velar closure.
Powered Transnasal Adenoidectomy
CONCLUSION
This procedure, which is advocated by Dr. Eji Yanagisawa, requires an endoscopic sinus surgery set and is not recommended for routine cases. 16 It should be reserved for superiorly situated adenoids that project into the nasal cavity or for when choanal obstruction persists that cannot be removed at the conclusion of standard transoral surgery. 16 The patient is positioned as for endoscopic sinus surgery. The nasal cavity is decongested with topical medication. If added exposure is needed, the inferior turbinates can be out fractured. A zero degree telescope is used to visualize the adenoids and the microdebrider is placed in either the ipsilateral or contralateral nostril. The adenoidal tissue is then removed under direct visualization. Occasionally, the inferior aspect of the adenoid bed cannot be removed via transnasal approach and the operation is then completed transorally. An advantage of this technique is the neutral position that the head and neck are maintained in. This is important in patients with cervical instability such as in children with Down syndrome.
Diseases of the adenoids cause a variety of upper respiratory tract symptoms in children, and an adenoidectomy has been shown to be an effective way to treat these problems. As a result, adenoidectomy is one of the most common procedures performed in children. There are many ways to perform an adenoidectomy effectively. The most commonly used tools today are the curette, the suction cautery, and the endoscopic shaver. What is common to all contemporary techniques is that visualization and surgical control of bleeding have become the accepted standard of care.
Powered Transoral Adenoidectomy Initially described in 1997, the transoral approach makes use of a bent endoscopic shaver blade and mirror visualization. The patient is placed in the Rose position. A modified Crowe-Davis type oral gag (designed by Dr. Max April and allows greater access to the nasopharynx with the shaver), is used to retract the lower jaw while the palate is retracted with catheters. Various shaver manufacturers make either prebent or bendable blades that allow the instrument access to the nasopharynx under indirect visualization with a mirror (Fig 2). Starting superiorly in the region of the choanal sill, the adenoids are removed in a side-to-side fashion, progressing inferiorly. Tissue is removed only at the site of the oscillating blade, which is kept in view at all times (Figs 3 and 4). By angling the blade, tissue immediately adjacent to the Eustachian tube can be easily and safely removed. The depth of the resection is also readily monitored. Once completed, a tonsil pack is placed in the nasopharynx for several minutes, and then any residual bleeding is controlled with suction cautery (Fig 5). When compared with the curette technique, this method was found to be significantly faster, resulted in less blood loss, and had an
202
ACKNOWLEDGEMENT We appreciate the assistance of Mr. Scott Beam in the preparation of this manuscript.
REFERENCES 1. Weir N: Otolaryngology--AnIllustrated History. Boston, MA, Butterworths, 1990 2. WiatrakBJ, WoolleyAL: Pharyngitisand adenotonsillardisease, in CummingsCW (ed): OtolaryngologyHead and Neck Surgery,vol 5 (ed 3). St. Louis,MO, Mosby-YearBook, 1998, pp 88-215 3. Sen AK, Gupta B: Herniationof RAE tube through split Boyle-Davis gag. Anesth Intens Care 18:577-578, 1990 4. WilliamsPJ, BaileyPM: Comparisonof the reinforcedlaryngealmask airway and tracheal intubationfor adenotonsillectomy.Br J Anesth 70:30-33, 1993 5. Martinez SA, Akin DP: Laser tonsillectomyand adenoidectomy. OtolaryngolClin North Am 20:371-376, 1987 6. GiannoniC, SulekM, FriedmanEM, et al: Acquirednasopharyngeal stenosis: A warning and review. Arch OtolaryngolHead Neck Surg 124:163-167, 1998 7. Sherman G: Innovative surgical procedure for adenoidectomy.Laryngoscope 92:700-701, 1982 8. ClemensJ, McMurrayJS, WillgingJP: Electrocauteryversus curette adenoidectomy:Comparison of postoperative results. Int J Pediatr Otorhinolaryngol43:115-122, 1998 9. Hartley BEJ, Papsin BC, Albert DM: Suction diathermyadenoidectomy. Clin Otolaryngol23:308-309, 1998 10. Wright ED, ManoukianJJ, Shapiro RS: Ablative adenoidectomy:A new techniqueusing simultaneousliquefaction/aspiration.J Otolaryngol 26:36-43, 1997 11. CannonCR,ReplogleWH, SchenkMP: Endoscopic-assistedadenoidectomy. OtolaryngolHead Neck Surg 121:740-744, 1999 CURRENTTECHNIQUESOF ADENOIDECTOMY
12. Becker SP, Roberts N, Coglianese D: Endoscopic adenoidectomy for relief of serous otitis media. Laryngoscope 102:1379-1384, 1992 13. Setliff RC, Parsons DS: The hummer. New instrumentation for endoscopic sinus surgery. Am J Rhinol 8:275-278, 1994 14. Parsons DS: Rhinologic uses of powered instrumentation in children beyond sinus surgery. Otolaryngol Clin North Am 29:105-114, 1996 15. Koltai PJ, Kalathia AS, Stanislaw P: Power assisted adenoidectomy. Arch Otolaryngol Head Neck Surg 123:685-688, 1997
DISCOLO, YOUNES,AND KOLTAI
16. Yanagisawa E, Ho SY, Mirante JP: Powered transnasal adenoidectomy, in Yanagisawa E, Christmas DA, Mirante JP (eds): Powered Instrumentation in Otolaryngology Head and Neck Surgery, Canada, Thomson Learning, 2001, p. 247 17. Heras H, Koltai PJ: Safety of powered instrumentation for adenoidectomy. Int J Pediatr Ot0rhinolaryngol 44:149-153, 1998 18. Masters FW, Bingham HG, Robinson DW: The prevention and treatment of hearing loss in the cleft palate child. Plast Reconstr Surg 25:503-509, 1960
20~