Graphic representation of the grading system used to evaluate choanal obstruction by adenoid hyperplasia. The diagram is oriented with the nasal septum on the right.
Preparation for the suction cautery adenoidectomy. The mouth gag and red rubber catheters are in position, and the laryngeal mirror is being used to examine the nasopharynx.
Detail of the view in the laryngeal mirror. To avoid injury, the suction tip is used to draw the choanal adenoid tissue inferiorly and medially (upper arrow) and the lateral adenoid tissue medially (lower arrow). Inset, The tip is inserted within (not on top of) the central bulk of the adenoid pad.
At the completion of the suction cautery adenoidectomy, the surface of the nasopharynx (arrows) should be smooth and the choanae completely visible.
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Wynn R, Rosenfeld RM. Outcomes in Suction Coagulator Adenoidectomy. Arch Otolaryngol Head Neck Surg. 2003;129(2):182–185. doi:10.1001/archotol.129.2.182
Copyright 2003 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2003
To assess the feasibility of suction coagulator adenoidectomy relative to adenoid size and to document patient-based outcomes and satisfaction with surgery.
Historical cohort study.
Referral-based academic pediatric otolaryngology practice.
Consecutive series of 118 children older than 3 years (mean age, 6.5 years) undergoing adenoidectomy alone.
Video nasopharyngoscopy followed by suction coagulator adenoidectomy as part of routine clinical care. An outcome survey was completed by telephone.
Duration of surgery, estimated blood loss, complications, parent satisfaction, and clinical outcomes.
The distribution of preoperative adenoid grades as determined by nasal endoscopy were as follows: grade 2 (≥33% to <66% choanal obstruction), 7%; grade 3 (≥66% to <90% obstruction), 48%; and grade 4 (90%-100% obstruction), 45%. The mean (SD) surgical time of 10.5 (3.0) minutes was unrelated to adenoid grade (R = 0.014; P = .88). All blood loss was less than 15 mL (<5 mL for 67%), and the only complication was a loose tooth. The parents of 98 patients (83%) were contacted a mean of 30.4 days after surgery: 95 (97%) reported less-labored breathing, and 94 (96%) were satisfied with the surgical results. Only 5 patients (5%) required a follow-up visit within 30 days of surgery.
Suction coagulator adenoidectomy proved safe and rapid, regardless of the adenoid size. Surgical outcomes were very favorable, with nearly all parents reporting satisfaction with the procedure and improvement in their child's breathing.
THE ADENOIDS, a group of lymphoid tissues in the posterior nasopharynx, become apparent clinically when they undergo hyperplasia. Hyperplastic adenoids contribute to obstructive sleep apnea and can act as a bacterial reservoir for recurrent acute otitis media and chronic sinusitis.1 Adenoidectomy, either alone or in combination with bilateral myringotomy and placement of tubes and/or tonsillectomy, is one of the most common major surgical procedures in the pediatric population. Traditionally, adenoidectomy is performed using cold curettage followed by nasopharyngeal packing to aid hemostasis.
Techniques using other instruments such as microdebriders and suction electrocautery have also been developed.2 Suction electrocautery has long been used to help achieve hemostasis after adenoidectomy.3 However, using suction electrocautery to perform the entire adenoidectomy is a relatively recent development.4,5 Electrical current is applied from the suction cautery to the adenoid pad to liquefy and ablate it under indirect visualization with a laryngeal mirror. This technique has the advantage of improved visualization because the entire procedure can be performed with the suction coagulator and laryngeal mirror simultaneously in place in the nasopharynx. In contrast, to perform the curette procedure, the mirror must be withdrawn to allow manipulation of the curette. The use of the suction tip also allows more precision in removing tissue around the vicinity of the choanae and the torus tubarius because those areas are more accessible to the smaller suction tip.
Furthermore, 3 studies comparing suction cautery adenoidectomy with the conventional curette adenoidectomy have shown estimated blood losses to be lower in the cautery procedure.6-8 Pressure hemostasis with tonsil packs is not required, and further hemostasis with electrocautery is rarely needed. Operative time is also shorter for the suction cautery technique than for the adenoid curette technique.6,7
Despite the advantages of greater precision, less blood loss, and increased efficiency, some authorities avoid the suction coagulator technique because of concerns over safety and practicality. More specifically, they suggest that the suction coagulator technique may cause serious nasopharyngeal burns or stenosis and may be unsuitable for large adenoid pads. Having used this technique at our institution since 1997, we consider these concerns unfounded. Therefore, we undertook a historical cohort study to (1) assess the safety and feasibility of suction coagulator adenoidectomy relative to adenoid size and (2) document patient outcomes and satisfaction with the surgery.
A historical cohort study of patients at a referral-based academic pediatric otolaryngology practice was undertaken. A total of 118 patients were identified who had adenoidectomy alone performed by one attending surgeon (R.M.R.) or under his direct supervision between July 1998 and June 2001 and who had preoperative nasal endoscopy documented by photograph. Patients undergoing concomitant procedures such as tonsillectomy or bilateral myringotomy and placement of tubes were excluded because it was not possible to ascertain the proportion of the operative time spent on each procedure. The patient's age, sex, presenting complaints (obstruction, sinusitis, or otitis media), and comorbidities (asthma, sinusitis, and allergic rhinitis) were obtained from the initial history and physical and progress notes.
Flexible video fiberoptic nasal endoscopy was performed on each patient preoperatively. Photographs were taken to document the extent of choanal obstruction. The degree of choanal obstruction was graded on the scale of 1 to 4 developed by Clemens and coinvestigators.6 The grade evaluation was based on the view through nasal endoscopy. The ratio of the obstructing adenoid pad from the roof of the nasopharynx to the soft palate at the level of the eustachian tube was assessed (Figure 1).
All patients underwent suction coagulator adenoidectomy performed by one attending surgeon (R.M.R.) or under his direct supervision under general endotracheal anesthesia. The operative report and operating room nursing logs were used to ascertain the estimated blood loss, the presence of complications, and the operative time.
A registered nurse contacted the families of the patients postoperatively to complete a 10-item operative outcome questionnaire. The parents were questioned about various issues, including postoperative bleeding, improvement in breathing, need for return visits, and satisfaction with the procedure. Parents were offered the opportunity to opt out of a return visit if the operative outcome was satisfactory. This approach was based on findings of other investigators who demonstrated similar outcomes between office-visit and telephone follow-up.9,10
To perform the suction coagulator adenoidectomy, the patient is placed in the standard Rose position in preparation for adenoidectomy after general anesthesia is achieved.2 A mouth gag is inserted. The palate is then examined to rule out the presence of a submucous cleft. Two red rubber catheters are inserted into the nares and out the mouth and then clamped to elevate the soft palate. A laryngeal mirror is used to examine the nasopharynx (Figure 2). A 10F malleable, insulated suction coagulator (E2505-10Fr; Valleylab, Boulder, Colo) is used at a setting between 30 and 45 W, depending on the child's age and size. The electrosurgery unit is set to monopolar coagulation and used in the spray mode with foot control. The malleable suction tip is bent to an appropriate angle for comfortable placement in the nasopharynx through the mouth, and the tip is inserted within, not on top of, the central bulk of the adenoid pad (Figure 3, inset). The current is applied using a foot-pedal control for several seconds, and as the tissue liquefies, the tip is gradually withdrawn. The tissue is not cauterized. If the tip is applied too superficially, there is excessive heat, smoke, crusting, and cauterization. The lateral adenoid tissue, near the torus, is drawn medially with the suction tip, and the choanal adenoid tissue is drawn inferiorly to avoid injury, as indicated by the arrows in Figure 3. The procedure is complete when the choana is completely visible and the nasopharynx has a smooth contour, as illustrated by the arrrows in Figure 4. There should be no significant burns on the vomer, nasal turbinates, soft palate, or lateral nasopharyngeal walls.
The ages of the patients in this study ranged from 5 months to 16 years, and the mean (SD) age was 6.5 (3.6) years; 53% of the patients were male and 47% female. The presenting complaints included obstructive symptoms (mouth-breathing and/or severe snoring) in 88% of the patients, sinonasal infection in 36%, and otitis media in 20%.
On nasal endoscopy, none of the patients who underwent adenoidectomy had grade 1 choanal obstruction. Seven percent of the patients had grade 2 obstruction; 48% had grade 3 obstruction; and 45% had grade 4 obstruction. The mean (SD) grade of choanal obstruction was 3.6 (0.6) (Table 1).
Operative times ranged from 5 to 18 minutes, with a mean (SD) of 10.5 (3.0) minutes. The mean operative time for adenoids causing grade 2 choanal obstruction was 9.3 (1.7) minutes, ranging from 7 to 12 minutes. Grade 3 obstructive adenoid pads required a mean operative time of 10.6 (2.8) minutes (range, 5-17 minutes). A mean operative time of 10.5 (3.3) minutes (range, 5-18 minutes) was recorded for adenoids causing grade 4 choanal obstruction. No statistically significant relationship between operative time and grade of choanal obstruction was seen (Spearman rank correlation, R = 0.014; P = .88).
The documented estimated blood losses ranged from 0 to 15 mL, with a mean (SD) blood loss of 10.8 (2.9) mL. In 67% of the procedures, the blood loss was less than 5 mL. The blood loss was not specified in approximately 20% of the operative reports. There was a single complication, a loosened deciduous tooth. No significant burns were noted at the conclusion of surgery in any child on the tori, vomer, soft palate, turbinates, or choanal arches.
Mean (SD) operative times in years 1, 2, and 3 of the study period were 10.8 (2.5) minutes, 11.1 (2.9) minutes, and 9.8 (3.2) minutes, respectively. There is a fair correlation between operator experience and operative time (R = −0.197; P = .03).
The parents of 98 patients (83%) were contacted by the nurse a mean (SD) of 30.4 (9) days after surgery (range, 9-52 days) and completed questionnaires. Only 1 patient had bleeding greater than 5 mL during the postoperative course, and this bleeding stopped before the parents sought intervention. Three patients required a return visit to the clinic or the emergency department during the first postoperative week. A total of 5 patients requested or required visits within the first postoperative month.
Seventy-nine percent of patients did not require or request a return visit. Of the 98 patient-parents who completed the survey, 95 (97%) reported that the patient's breathing was less labored. Ninety-four (96%) of the parents contacted were satisfied with the outcome of the procedure.
Despite declines in the number of overall pediatric adenoid and/or tonsil procedures, adenoidectomy remains one of the most common procedures in children. Many well-established techniques of performing adenoidectomy already exist. Adenoidectomy using suction electrocautery has recently evolved and is becoming established as an acceptable alternative to traditional cold methods.
Our results show that suction coagulator adenoidectomy is a time-efficient procedure, regardless of the extent of obstruction by the adenoid pad. This relationship has not been examined before, and our findings suggest that the technique may be applied to adenoid pads of any size without appreciably increasing operative time in the cases of the larger or more obstructive ones. The operative time, however, appears to be influenced by the surgeon's experience.
The key to achieving rapid and effective ablation of a large adenoid pad is the use of liquefaction, not cauterization. The adenoid tissue is liquefied by placing the coagulator tip within the tissue and gradually withdrawing the tip as the current is applied. The current is released just prior to removing the tip from the adenoid. In contrast, cauterization involves the ablation of the adenoid from the adenoid inward. This creates an obstructing char that interferes with removing a large pad.
The documented blood loss in the present and prior studies was low. Previous studies comparing blood loss between suction cautery adenoidectomy and curette adenoidectomy illustrate the significantly smaller blood loss associated with the suction cautery technique.6-8 Although the present study does not compare the blood loss with that of the curette procedure, our findings clearly corroborate the preexisting evidence that the blood loss is minimal and acceptable. There is no need for postadenoidectomy nasopharyngeal packing, and rarely is further suction cautery hemostasis required, which may also save operative time.
Among 118 patients, there was a single complication, a loosened tooth, which was not a permanent tooth. The complication was related to the use of the mouth gag, which is common to any technique of adenoidectomy and is usually easily managed with a dental consult. The absence of any significant burns to the surrounding tissues during all the procedures makes it extremely unlikely that nasopharyngeal stenosis could occur. Although we did not perform postoperative endoscopy, Clemens and his coinvestigators6 did perform such postoperative endoscopy in a smaller group of children and observed excellent healing with no evidence of scarring.
Wright et al7 and Walker8 found no difference in complication rates between curette and suction cautery adenoidectomy. However, the use of suction cautery for adenoidectomy could theoretically reduce the incidence of certain adenoidectomy complications. For instance, with conventional curette adenoidectomy, there is the risk of cervical osteomyelitis and postoperative nasal synechiae or stenosis. The risk of cervical osteomyelitis should be lower with the suction coagulator procedure than with the curette procedure because in the former, the adenoid pad is reduced carefully and with excellent visibility, easily avoiding deep excavations. Structural complications such as nasal stenosis or synechiae can also be more easily avoided with the improved visualization. Clemens et al6 and Walker8 found no evidence of nasopharyngeal stenosis. Also, in patients at risk for velopharyngeal insufficiency, the more precise nature of the suction cautery adenoidectomy makes it ideal for performing a partial adenoidectomy.
Operative outcomes as measured by the survey portion of the present study are extremely favorable. Most of the parents who responded to the postoperative outcome survey were satisfied with the surgery and reported improved breathing, which is reflected in the low number of patients requesting or requiring return visits during the first postoperative month.
In conclusion, suction coagulator adenoidectomy is a relatively new technique that is acceptable, safe, rapid, and suitable for adenoids of any size. Optimal efficiency and results are achieved when the adenoid tissue is liquefied internally, not cauterized on the surface. The documented blood loss was minimal, and the operative time was reasonably short. No statistically significant correlation between the size of the adenoid pad and operative time was seen, suggesting that the procedure is feasible for all adenoidectomies. In addition, nearly all the parents surveyed were satisfied with the results and indicated that the patients experienced an improvement in breathing. These results, however, must be interpreted cautiously because of positive response bias when assessing outcomes with a nonvalidated outcomes survey.
Corresponding author: Rhoda Wynn, MD, Department of Otolaryngology, State University of New York Downstate Medical Center, 134 Atlantic Ave, Brooklyn, NY 11201 (e-mail: Rhoda_Wynn@hotmail.com).
Accepted for publication July 18, 2002.
This article was presented at the poster session of the annual meeting of the American Society of Pediatric Otolaryngology, Boca Raton, Fla, May 12, 2002.
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