European Journal of Cardiovascular Medicine

Adenoidectomy is among the most common operations performed in children worldwide. Symptoms of nasal obstructions, snoring and sleep-disordered breathing can significantly impair a child’s quality of life and may have unfavorable developmental effects that predispose the child to sleep-related breathing abnormalities. [1,2] 

Adenoidectomy in children is a difficult operation to perform. A unique challenge the surgeon faces following adenoid removal is adenoid regrowth from residual or recurrent adenoid tissue. Blind digital palpation was traditionally used to confirm the potential completeness of an adenoidectomy. Endoscopic assisted adenoidectomy (EAA) is a natural progression of this technology, can now be performed with visualisation facilitating complete adenoidectomy. [3,4]

Since early 90's with the innovations in the technology and techniques, some authors have defined excising adenoid tissue with various instruments like microdebrider under visualisation of the adenoidectomy surgical field, with a laryngeal mirror, trans-nasal or trans-oral endoscope [5]. Using endoscopes to visualize surgical field provides removing the residue adenoid tissue at the upper part of the nasopharynx, the choane and the peritubal region. In addition, the probability of harming the Eustachian tube orifice and/or of pharyngeal muscles is reduced and bleeding detection and treatment can be done smoothly [6]. After the CA, there may be transient Eustachian dysfunction and aural fullness caused by probable post-surgery clots and edema in nasopharynx [7]. This study aimed to determine remnant adenoid tissue performed using different surgical techniques.

A retrospective observational study conducted at government ENT hospital on children between 2017 and 2019 diagnosed with chronic adenoiditis.

In a study of 130 children, with obstructive adenoidal hypertrophy who had undergone consecutive adenoidectomy, it was demonstrated that endoscopic assisted adenoidectomy enables complete removal of obstructive adenoid tissue, greater in total mass in a more precise manner thereby ensuring better post-nasal patency. 50 children where include and diagnosed with chronic adenoiditis.

Inclusion criteria: children aged between 5-15years with adenoid hypertrophy grade 2 and higher (based on detailed history by clinical questionnaire, cephalometric radiography and nasal endoscopy)

Exclusion criteria: Conditions that mimic adenoid hypertrophy like Nasal polyposis, nasal angiofibroma, nasopharyngeal carcinoma Children with craniofacial abnormalities, neurological disorders.

Children were randomly divided and subjected to either technique of surgery. group A (20) included children who underwent conventional adenoidectomy, group B (20) children who underwent endoscopic assisted (coblation & microdebrider) adenoidectomy. Group C (10) combined technique.

Patients after being discharged were subjected to follow-up on 1st week and 6th week from date of surgery. Review is done clinically in 1^st week and by endoscopic and radiologic assessment at 6^th week.

The data between two groups were compared using Mann Whitney test and significance was ascertained using p value.

Findings were based on study over 50 patients among whom 20 underwent conventional adenoidectomy and 20 children underwent endoscopic assisted adenoidectomy 10 children underwent combined approach.

Table-1: Comparison of residual adenoid tissue with different techniques

In our study , children with conventional curettage (40%)  had high incidence of recurrence (40%) , subjects who underwent endoscopic guided adenoidectomy (40%) had minimal incidence of recurrence (5%) whereas those subjects who underwent combined approach (20%) had negligible recurrence (0%).

The use of endoscopic equipments allows the adenoid to be removed piece by piece under vision. In our study, children with conventional curettage had high incidence of recurrence  , subjects who underwent endoscopic guided adenoidectomy had minimal incidence of recurrence whereas those subjects who underwent combined approach had negligible recurrence. However, in patients with a very large adenoid, endoscopic removal requires more time than conventional surgery, which prolongs the need for anaesthesia and increases its risk, as studied by Huang HM et al[8], same observations correlate with our study.

Canon CR et al[9] found that after conventional adenoidectomy, there is always residual tissue in the posterior superior choana of nose and nasopharynx . Endoscopic assisted technique allows more complete removal of adenoid tissue without significant increase in the operative time, blood loss or association with any post operative complications . In our study these observations correlate with previous study.

Complications after TA were reported as ranging from 28.5% in study done by Al-Mazrou [10]  to 0 in study by Murray et al.[11], while PEA showed a lower complication rates ranging from 25% in Al-Mazrou et al   to 1.1% Stanislaw et al [12] study. In our study no complications  of patients undergoing adenoidectomy. Though PEA performs better than most literature reports on TA, it is interesting though how selected TA case series with no complication rates[11] did not differ significantly from our case series. When comparing our study of complications with other PEA literature reports, ours is comparable only to studies including at least 50 patients[12]. This decrease in complications rate in larger case series may be the results of more solid surgical experience in the technique. Nevertheless, in our experience, PEA showed a shallow learning curve, with younger specialists getting a swift hold on the technique, both in terms of surgical times and complication rates.

According to findings from the study of Sureyya hikmet kozcu[13] the EMA procedure may be as safe and rapid as the CA. Furthermore, the EMA may be more controlled and less invasive to the surrounding tissues.

Our group had only 2 surgeons while the Grindle et al[14] group included 15, which may account for a smaller number of procedures identified in our study.1 In the study by Dearking et al[15], 8,245 primary adenoidectomies were identified over a 29-year period in children under 18years, with 163 revision cases.5 In the study by Sapthavee et al[16], 7,399 primary adenoidectomies were identified over a 4-year period in children under 18 years with 120 revision cases, although only 85 were examined in more detail.

The combination of conventional and endoscopic approaches in these patients will shorten the operative time to remove the adenoid. Shin and Hartnick[17] studied three cases in which operative time for the adenoidectomy portion of the procedure, including endoscopic equipment setup and photo documentation, was 10 to 15 minutes. In our study also, there is only a minimal increase in the operating time taken for EAA. Cannon et al[2] found that after conventional adenoidectomy, there is always residual tissue in the posterior superior choana of the nose and nasopharynx. Conventional adenoidectomy combined with endoscopic-assisted removal allows complete removal of adenoid tissue without a significant increase in the operative time, blood loss, or association with any postoperative complications. I

Endoscopic-assisted adenoidectomy is an adjunct to performing a more complete adenoidectomy, thereby reducing the chances of developing recurrent adenoid obstructive symptoms thereby reducing bacterial reservoir in the nasopharynx. EAA significantly decreases the operative time, blood loss and association with post-operative complications.

The procedure costs more because of the additional equipment needed. The combination of conventional and endoscopic approaches in the patients will shorten the operative time and also facilitates complete removal of  the adenoid. Endoscopic-assisted adenoidectomy is an adjunct to perform a more complete adenoidectomy, thereby improving the quality of life and by avoiding the complications of chronic recurrent adenoiditis.

Both the conventional adenoidectomy in experienced hands and endoscopic assisted adenoidectomy have comparable success. Patients undergoing adenoidectomy with curettage are at increased risk of recurrence with residual tissue requiring repeat adenoidectomy. Therefore performing adenoidectomy without visualization could lead to adenoid regrowth because of incomplete removal.

Endoscopic assisted adenoidectomy is an adjunct to perform a more complete adenoidectomy thereby improving the quality of life and avoiding complications such as chronic recurrent adenoiditis. The use of endoscopic equipments  allows the adenoid to be removed piece by piece under vision.

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