Adenoidectomy

Definition

An adenoidectomy is the surgical removal of the adenoids—small lumps of tissue that lie in the back of the throat behind the nose.

Purpose

The adenoids are removed if they block breathing through the nose and if they cause chronic earaches or deafness. The adenoids consist of lymphoid tissue—white blood cells from the immune system. They are located near the tonsils, two other lumps of similar lymphoid tissue. In childhood, adenoids and tonsils are believed to play a role in fighting infections by producing antibodies that attack bacteria entering the body through the mouth and nose. In adulthood however, it is unlikely that the adenoids are involved in maintaining health, and they normally shrink and disappear. Between the ages of two and six, the adenoids can become chronically infected, swelling up and becoming inflamed. This can cause breathing difficulties, especially during sleep. The swelling can also block the eustachian tubes that connect the back of the throat to the ears, leading to hearing problems until the blockage is relieved. The purpose of an adenoidectomy is thus to remove infected adenoids. Since they are often associated with infected tonsils, they are often removed as part of a combined operation that also removes the tonsils, called a T&A ( tonsillectomy and adenoidectomy).

Demographics

Demographics information is difficult to provide because adenoidectomy is routinely performed in an outpatient setting, for which demographic data are not well recorded. Good information is available from the 1970s and 1980s when the surgery was performed in an inpatient setting. In the United States in 1971, more than one million combined T&As, tonsillectomies alone, or adenoidectomies alone were performed, with 50,000 of these procedures consisting of adenoidectomy alone. In 1987, 250,000 combined or single procedures were performed, with 15,000 consisting of adenoidectomy alone. Now, almost all adenoidectomies are performed on an outpatient basis unless other medical problems require hospital admission or an overnight stay. T&A is considered the most common major surgical procedure in the United States.

Description

An adenoidectomy is performed under general anesthesia. The surgeon removes the adenoids from behind the palate. Stitches are usually not required.

Excision through the mouth

The adenoids are most commonly removed through the mouth after placing an instrument to open the mouth and retract the palate. A mirror is used to see the adenoids behind the nasal cavity. Several instruments can then be used to remove the adenoids.

• Curette removal. The most common method of removal is using the adenoid curette, an instrument that has a sharp edge in a perpendicular position to its long handle. Various sizes of curettes are available.
• Adenoid punch instrument. An adenoid punch is a curved instrument with a chamber that is placed over the adenoids. The chamber has a knife blade sliding-door to section off the adenoids that are then housed in the chamber and removed with the instrument.
• Magill forceps. A Magill forceps is a curved instrument used to remove residual adenoid, usually located deeper in the posterior nasal cavity, after attempted removal with curettes or adenoid punches.

Patient's mouth is held open with tubes (A). A mirror is used to visualize the adenoids during the procedure (B). The adenoids are removed with a side-to-side or front-to-back motion (C). Bleeding is controlled with a cauterizing tool (D). (

Illustration by GGS Inc.

)

• Electrocautery with a suction Bovie. The adenoids can also be removed by electrocautery with a suction Bovie, an instrument with a hollow center to suction blood and a rim of metal to achieve coagulation.
• Laser. The Nd:YAG laser has also been used to remove the adenoids. However, this technique has caused scarring of tissue and is usually avoided.

Excision through the nose

Adenoids may also be removed through the nasal cavity with a surgical suction instrument called a microdebrider. With this procedure, bleeding is controlled either with packing or suction cautery.

Diagnosis/Preparation

The primary methods used to determine whether adenoids need removal are:

• medical history
• physical examination
• throat bacterial cultures
• x rays
• blood tests

When the patient arrives at the hospital or the day-surgery unit, a nurse or a doctor will ask questions concerning the patient's general health to make sure he or she is fit to undergo surgery. They will also check that the patient has not had anything to eat or drink and will record pulse and blood pressure. The doctor or nurse must be informed if the patient has had any allergic or unusual reactions to drugs in the past. The patient will be asked to put on a hospital gown and to remove any loose orthodontic braces, false teeth, and jewelry. In the past, an adenoidectomy usually called for an overnight stay in hospital. However, it is increasingly more common to have this operation on an outpatient basis, meaning that the patient goes home on the same day. The surgery is usually performed early in the morning to allow a sufficient observation period after the operation.

Aftercare

After surgery, the patient wakes up in the recovery area and is given medication to reduce swelling and pain. When the patient has recovered from surgery, he or she is sent home and usually given a week's course of antibiotics to be taken by mouth. The patient may also develop a sore throat, especially when swallowing or speaking, or moderate pain at the back of the nose and throat, for which pain medication is prescribed. Normally, the pain goes away after a week. A child who has undergone an adenoidectomy should rest at home for at least one week to avoid possible infections at school. Swimming should not be allowed for at least 10 days after the operation. If there is any sign of bleeding or infection (fever, increased pain), the treating physician should be immediately contacted.

Risks

Risks and complications include those generally associated with surgery and anesthesia. Very few complications are known to occur after this operation, except, very rarely, bleeding (which occurs in 0.4% of cases). Bleeding is more a concern with a very young child because he or she often will not notice. For this reason, a child is always kept in observation at the hospital or clinic for a few hours after the operation. If bleeding does occur, the surgeon may insert a pack of gauze into the nose to stop the blood flow for subsequent removal after a day or two. The other possible complications are those associated with any operation, including infection of the operated area, which may result in light bleeding, increased pain, and fever. Infection is usually treated with antibiotics and bed rest.

Normal results

Adenoidectomy is an operation that has very good outcomes, and patients are expected to make a full and quick recovery once the initial pain has subsided. Adenoid tissue rarely regrows, but some instances have been reported. The exact mechanism is unknown but may be related to incomplete removal.

Alternatives

There is no good evidence supporting any curative non-surgical therapy for chronic infection of the adenoid.

Antibiotics have been used for as long as six weeks in lymphoid tissue infection, but with failure to eradicate the bacteria. With reported incidences of drug-resistant bacteria, use of long-term antibiotics is not a recommended alternative to surgical removal of infected adenoids.

Some studies indicate some benefit from using topical nasal steroids. Studies show that while using the medication, the adenoids may shrink up to 10% and help relieve nasal blockage. However, once the steroid medication is stopped, the adenoids can again enlarge and continue to cause symptoms. In a child with nasal obstructive symptoms, a trial of topical nasal steroid spray and saline spray may be attempted for controlling symptoms.

Resources

books

Bluestone, C. D. Pediatric otolaryngology Philadelphia: Saunders, 2003.

Lee, K. J. Essential otolaryngology: head and neck surgery. New York: McGraw-Hill Medical Pub. Division, 2003.

Markel, H. and F. A. Oski. The Practical Pediatrician: The A to Z Guide to Your Child's Health, Behavior, and Safety. New York: W. H. Freeman and Co., 1995.

periodicals

Felder-Puig, R., A. Maksys, C. Noestlinger, et al. "Using a children's book to prepare children and parents for elective ENT surgery: results of a randomized clinical trial." International Journal of Pediatrics and Otorhinolaryngology 67 (January 2003): 35–41.

Homer, J. J., J. Swallow, and P. Semple. " Audit of pain management at home following tonsillectomy in children." Journal of Laryngology and Otology 115 (March 2001): 205–208.

Kokki, H. and R. Ahonen. "Pain and activity disturbance after paediatric day case adenoidectomy." Paediatric Anaesthesiology 7 (1997): 227–231.

Kvaerner, K. J., P. Nafstad, and J. J. Jaakkola. "Otolaryngological surgery and upper respiratory tract infections in children: an epidemiological study." Annals of Otology, Rhinology and Laryngology 111 (November 2002): 1034–1039.

McClay, J. E. "Resistant bacteria in the adenoids: a preliminary report." Archives of Otolaryngology: Head and Neck Surgery 123 (May 2000): 625–629.

organizations

American Academy of Otolaryngology - Head and Neck Surgery. One Prince Street, Alexandria, VA 22314. (703) 806-4444. http://www.entnet.org .

American College of Surgeons. 633 N. Saint Claire St., Chicago, IL 60611. (312) 202-5000. http://www.faacs.org .

other

American College of Surgeons. "Tonsillectomy and Adenoidectomy." February 21, 2003 [cited April 23, 2003]. http://www.facs.org/public_info/operation/aboutbroch.html .

BUPA. "Adenoidectomy." [cited April 23, 2003]. http://www.bupa.com .

Texas Pediatric Surgical Associates. "Adenoids and Adenoidectomy." [cited April 23, 2003]. http://www.pedisurg.com/PtEducENT/adenoids.htm .

Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An adenoidectomy is performed by an ENT (ear, nose, and throat) board-certified surgeon.

QUESTIONS TO ASK THE DOCTOR

• What are the possible complications involved in this type of surgery?
• Should the tonsils be removed as well?
• Could my child outgrow the problem?
• How are adenoids removed in your clinic/hospital?
• Is there a special diet to be followed after the operation?
• How much adenoidectomies do you perform each year?