Paediatric adenoidectomy surgery technique - Vula - University of ...

The space lateral to the adenoid and posteromedialto the orifice of the Eustachiantube is termed the fossa of Rosenmüller.Gerlach’s tonsil refers to a collection oflymphoid tissue located within the lip ofthe fossa of Rosenmüller and can extendinto the Eustachian tube. Inferiorly, theadenoids abut the upper margin of thesuperior constrictor or Passavant’s ridge(Figure 2).(Table 1). This is best achieved by flexiblenasendoscopy in an awake patient (ifpossible) or with a dental mirror placed inthe postnasal space in an anaesthetisedpatient.Grade Choanal obstruction1 < 1/32 1/3 - 2/33 2/3 - 3/3Table 1: Grading system for adenoid sizeSurgical equipmentFigure 2: View from below of adenoidsextending superiorly from Passavant’sridge (broken yellow line)The arterial blood supply to the adenoidarises from branches of the external carotidartery i.e. ascending pharyngeal, ascendingpalatine, sphenopalatine, pharyngealbranch of maxillary artery, and artery ofthe pterygoid canal. Venous drainage is tothe facial and internal jugular systems.Sensory innervation is provided by theglossopharyngeal (IX) and vagus (X)nerves; this explains the referred pain thatpatients experience to the ear and throatwith adenoid infection and followingadenoidectomy.Grading of adenoidal sizeThe percentage of choanal obstruction isoften used to grade the size of adenoidsAn adenoid curette and/or suctiondiathermy are commonly used to performadenoidectomy. Advantages of suction diathermyinclude targeted, directed removalof the adenoids avoiding injury to adjacentstructures, clearing choanal adenoidaltissue and haemostasis. Figures 3-5 illustratethe equipment required to performadenoidectomy with a curette and withsuction diathermy.Figure 3: Instruments used to performcurette adenoidectomy: curettes, Boyle-Davis gag and tonsil swabs2

clip to retract the soft palate anteriorly(Figure 7)Figure 4: Instruments used to performadenoidectomy with suction diathermy:monopolar suction diathermy, Boyle-Davisgag, dental mirror, Burkitt straight forcepsand suction catheterFigure 6: Boyle Davis gag in placesuspended and held in place withDrafton rodsFigure 5: Drafton rods are used tosuspend the Boyle Davis gag and stabilizethe headPreliminary stepsGeneral anaesthesia with endotrachealintubation using an angled tube or witha laryngeal maskPatient is positioned supine with ashoulder roll to achieve extension ofthe neckA Boyle Davis mouth gag is inserted;ensure that the ventilation tube and tongueare in the midline (Figures 3, 4, 6)Open the gag to expose the oropharynxStabilise the patient’s head in thedesired position by inserting Draftonsuspension rods (Figure 6)To improve the view of the nasopharynx,insert a nasal catheter in one/bothnostrils and bring it out through themouth; secure both ends with an arteryFigure 7: Note the nasal catheterretracting soft palate anteriorlyAssess the size of the adenoids andexclude an aberrant or dehiscent internalcarotid artery by examining thenasopharynx with a dental mirror and /or by digital palpationPalpate the palate to exclude an occultsubmucous cleft palate; proceedingwith adenoidectomy in such cases cancause rhinolalia aperta3

Curette AdenoidectomyUse the largest adenoidectomy curettethat will engage the adenoidsUsing a dental mirror aids the surgeonto place the curette under direct visionStabilise the head with the nondominanthandRemove the adenoids with a singlefirm scraping motion from superiorlyto inferiorlyInspect the adenoid bed to assesswhether removal is complete; if not,repeat the process until completeremoval has been achievedPlace swabs/sponges in the postnasalspace while continuing with the tonsillectomyif indicatedRemove the swabs after a few minutesConfirm haemostasis by inspecting thenasopharynx with a mirrorHaemostasis can be achieved by usingmonopolar suction diathermy; tt isabsolutely essential that there iscomplete haemostasisRemove all clots from the nose andnasopharynx with a suction catheterpassed through the noseDocument in the operation notes thathaemostasis has been achieved andclots clearedUsing a combination of sweepingmotions and localised "spot welding",remove or ablate the adenoids underdirect vision until a clear view of theposterior choanae is obtained (Figure9)Suction Diathermy AdenoidectomyBend the tip of the suction diathermyto 90 degrees with the introducer stillin place so as to prevent kinking andocclusion of the lumen (Figure 8)Remove the introducer and connectcontinuous suctionSet the monopolar diathermy at 38WattsWith a mirror held in the non-dominanthand, pass the suction diathermybehind the palate4

Postoperative CareAdenoidectomy is commonly performed asa day case procedure. Paracetamol isusually sufficient to control postoperativepain. If suction diathermy was used, broadspectrum antibiotics (co-amoxiclav) isadministered for a week post-operativelyto treat the resulting nasal discharge.Patients are advised to miss school for 5days and generally recover within a week.Complications following adenoidectomyEarlyLateBleeding (more commonly with curetteadenoidectomy)Aspiration of retained blood clotcausing acute airway obstruction(Coronor’s clot)Nasal discharge (suction diathermy)Grisel syndrome (atlanto-axial instability)Scarring of Eustachian tube openingcausing middle ear dysfunctionNasopharyngeal stenosisVelopharyngeal insufficiencyRegrowth of adenoidsAuthor and Paediatric Section EditorNico Jonas MBChB, FCORL, MMedPaediatric OtolaryngologistAddenbrooke’s HospitalCambridgeUnited Kingdomnico.jonas@gmail.comEditorJohan Fagan MBChB, FCORL, MMedProfessor and ChairmanDivision of OtolaryngologyUniversity of Cape TownCape Town, South Africajohannes.fagan@uct.ac.zaTHE OPEN ACCESS ATLAS OFOTOLARYNGOLOGY, HEAD &NECK OPERATIVE SURGERYwww.entdev.uct.ac.zaThe Open Access Atlas of Otolaryngology, Head &Neck Operative Surgery by Johan Fagan (Editor)johannes.fagan@uct.ac.za is licensed under a CreativeCommons Attribution - Non-Commercial 3.0 UnportedLicense5