Adenoidectomy operation is one of the common causes of general anesthesia to the children. Chronic nasal obstruction, mouth open sleep, snoring, sleep apnea, otitis media with effusion, chronic rhinosinusitis and craniofacial changes are warning signs for adenoid hypertrophy. The diagnosis of adenoid hypertrophy can be confirmed by nasal endoscopic view and X-rays. The surgical techniques and instruments being used for adenoidectomy has been changed over the years. Several different surgical technics are described in the literature [5]. In this study conventional cold curettage adenoidectomy was compared with endoscopic assisted microdebrider adenoidectomy in terms of safety and recurrence.
Conventional cold curettage adenoidectomy is the oldest technique which is performed by adenotome curettes with proper angle and length, and it is usually performed for large adenoids. The biggest disadvantage of this method is resecting adenoid tissue blindly. In this technique torus tubarius, nasopharyngeal mucosa and prevertebral fascia can be easily damaged. The incidence of residual adenoid tissue is also a further disadvantage [6]. Complete resection of adenoid tissue can be difficult with these traditional instruments. Residual adenoid tissue is seen with high rates immediately after classical adenoidectomy by inspection of nasopharynx especially at the posterior side of nasopharynx, choana, peritubal region [7, 8]. Residual tissue, recurrence of the symptoms can lead to a revision surgery and potential damage risk to the structures in this area is an avoiding issue [9, 10].
Several new technics like vacuum diathermy, microdebrider, gold laser, coblator are described to reduce the disadvantages of conventional methods [2]. The frequency of using endoscopic assisted microdebrider for adenoidectomy is being increased because of its advantages. This technic provides a controlled resection of adenoid tissue on the posterior wall and nearby torus tubarius region. However, if the adenoid tissue is huge and full fill the choana, using only microdebriders can cause the prolongation of the operation and difficulty in resection of all adenoid tissue because of microdebrider instruments have a limited maneuverability at inferior side of nasopharynx [11].
Some studies comparing surgical methods show that adenoidectomy with microdebrider or shaver is more advantageous than classical adenoidectomy [10, 12]. Ozturk at all [10] have compared the transoral power-assisted endoscopic adenoidectomy with curettage adenoidectomy in a prospective randomized study and they reported that transoral power-assisted endoscopic adenoidectomy has more advantages like short operation time, better exposure, and effective hemostasis. Another study shows that microdebrider adenoidectomy can be faster when partial adenoidectomy is performed [12].
In a study of 40 cases, which compares microdebrider adenoidectomy with conventional cold curettage adenoidectomy technique, microdebrider technique was found to be faster and causing less bleeding [13]. On the other hand, Businco et al[14] stated that cold curetage adenoidectomy was faster than coblation adenoidectomy, because coblation needed more preparation. Koltai et al[15] stated that microdebrider adenoidectomy caused more bleeding, but post-op bleeding rate was same as classic technique. Revision rates were between 0.5–3% regardless of technique [3, 16]. Grindle et al[3] stated revision indications as adenoid hypertrophy, chronic adenoiditis, obstructive sleep apnea, sinusitis, and otitis media. In the present study we encountered an overall revision rate as 2,04%, and this was compatible with the literature. Despite a recent metanalysis indicating a lack of strong evidence correlating surgical techniques with revision rate in pediatric adenoidectomy, there was no relapse in endoscopic microdebrider adenoidectomy group in the present study [17]. We think the revision rate can be minimized under careful inspection in endoscopy and meticulous resection with microdebrider.
Adenoidectomy, particularly if occluding nasopharynx and choana may cause an increase in the depth of the nasopharynx. If the velum is not long enough to reach the posterior pharyngeal wall after the adenoidectomy, velopharyngeal insufficiency (VPI) may occur. VPI results in hypernasality while speaking. Some children may have a temporary VPI after adenoidectomy. The speech symptoms generally resolve spontaneously in 4–6 weeks. However permanent VPI is a risk especially for a child with cleft palate or submucous cleft. Partial adenoidectomy is used to remove a selected part of adenoid tissue that relieves nasal obstruction symptoms and preserves the function of the velopharyngeal sphincter to avoid postoperative hypernasality. [18]. In a recent systematic review of online databases concluded that sub-total adenoidectomy in patients with submucosal cleft palate or repaired cleft palate appears to be a safe and efficacious procedure [19]. Parton et al[20] stated that preoperative assessment is crucial in preventing hypernasality. Every patient who has an adenoidectomy indication was routinely examined by digital palpation to rule out cleft palate or submucous cleft in our clinic. Although patients with cleft palate or submucous cleft were not included in the present study postoperative overall temporary hypernasal speaking rate was 3,84% (4,01% in CCA, 3,61% in EMA). All these cases were normal after 6 months.
As an obstructive mass or an infectious focus in the nasopharynx is thought to increase otitis media and middle ear problems. However, the efficacy of adenoidectomy in recurrent otitis media has been stated as controversial [21]. Otitis media with effusion after adenoidectomy may be due to eustachian tube orifice injury, because of it is adjacent to the adenoids and can be injured from the injudicious use of the curette or other instruments. Recurrent otitis media attacks after adenoidectomy should raise doubt to periorificial injury, and these patients should be under near follow up. To the best of our knowledge and a Pubmed search, acute otitis media after adenoidectomy is a less reported issue. From the abstract of a follow-up study in Japanese, 92 patients with secretory otitis media who underwent adenotomy or adeno-tonsillectomy were evaluated, and even after the operations, one-third of the patients experienced acute otitis media, recurrence and elongated cure were found in 75% and 25% of these ears, respectively [22]. In our study overall otitis media rate was 4,20%. In Group A and B postoperative otitis media rates were 5,91% and 1,94%, respectively. Also %1.44 of our patients had ventilation tube insertion for prolonged otitis media with effusion.
Even though it is proven that both techniques are safe in experienced hands, some complications may occur, and can be overcome with correct and timely intervention.