Comparative Study Between Conventional Curettage Adenoidectomy Versus Endoscopic Microdebrider Assisted Adenoidectomy: Our Experience

Abstract

Adenoidectomy is one of the commonest surgical procedures performed by otolaryngologists however; its recurrence rates are very high. Our objective in this study was to compare safety and efficacy between conventional curettage and endoscopic assisted microdebrider adenoidectomy. This was a prospective comparative parallel randomized control trial conducted at a tertiary care hospital from April 2017 to December 2018. We divided patients (N = 42) into two groups i.e. conventional adenoidectomy (group A) (n₁ = 21) and endoscopic microdebrider assisted adenoidectomy (group B) (n₁ = 21) groups using the lottery method of randomization. Among 42 patients, 33 (79%) were male and 9 (21%) were female. The average operative time in group A was 16.15 min and in group B was 22.9 min with p value < 0.05. Average blood loss in group A was 35.57 ml and in group B was 37.14 ml. In group A, 1 (4.76%) of 21 patients developed temporary velopharyngeal insufficiency which was relieved after 4 weeks of surgery whereas in group B, 5 (23.8%) patients developed nasal bleed and 2 (9.52%) patients presented with nasal synechiae on follow-up. Eight (38%) patients in group A showed grade I adenoids after 3 weeks of surgery while group B showed complete clearance in all patients (p < 0.05). Conventional adenoidectomy has less intra-operative blood loss and shorter surgical time duration as compared to endoscopic assisted microdebrider adenoidectomy but with higher chances of residual adenoid tissue.

Introduction

Adenoid, also known as the nasopharyngeal tonsil, is a mass of lymphoid tissue found in the poster superior wall of the nasopharynx. Adenoids, along with palatine and lingual tonsils, belong to mucosa associated lymphoid tissue and constitute the major part of the Waldeyer’s ring. Adenoid was initially described by Meyer in 1868 as a nasopharyngeal lymphoid tissue which forms a part of the Waldeyer’s ring [1]. Adenoid hypertrophy can result in upper airway obstruction in children. Children with this condition present with symptoms of chronic nasal obstruction, rhinorrhoea, mouth breathing, snoring, recurrent sinusitis, feeding difficulties, craniofacial abnormalities and recurrent otitis media with effusion.

Adenoidectomy with or without tonsillectomy is one of the most common surgical procedure performed by otolaryngologists in the pediatric population. Various techniques have been proposed in order to reduce the amount of bleeding during the procedure and to facilitate the easy and safe removal of adenoid tissue. It can be done using an adenoid curette, bipolar cautery, power assisted microdebrider and the co-ablator. The ideal approach should relieve the obstruction and leave minimal or no tissue in the nasopharynx and achieve good postoperative results. The standard adenoidectomy technique is to remove the nasopharyngeal lymphatic tissue with an adenoid curette or an adenotome. However, recurrence rates following adenoidectomy are very high due to certain factors like difficult access of adenoids and the non-visualization of adenoids during removal. Dissatisfaction with conventional technique in adequately and safely removing the adenoid tissue has led to the development of alternative methods, including endoscope guided power-shaver adenoidectomy with the use of fiber optics and endoscopic instrumentation which has the advantage of visualizing the adenoid tissue as well as the surrounding structures and thus enabling better removal of the whole adenoid tissue without injuring the other structures like eustachian tube opening and posterior choana [2, 3].

Our primary objective in this study was to compare safety and efficacy between conventional curettage and endoscopic assisted microdebrider adenoidectomy. Our secondary objective was to compare the two techniques in terms of intra-operative blood loss, total resection time, associated trauma to surrounding structures, clearance of the adenoids, postoperative bleeding, infections, residual tissue, and other complications.

Methods

This was a prospective comparative parallel randomised control trial with an allocation ratio of 1:1. The study was conducted at the department of otorhinolaryngology and head–neck surgery, Baroda Medical College and SSG hospital from April 2017 to December 2018. All patients (N = 42) who presented with complaints of mouth breathing, nasal obstruction, snoring, recurrent ear discharge, and recurrent throat pain to the otorhinolaryngology and head–neck surgery out and in-patient departments as well as referrals from pediatric department were included in the study. Exclusion criteria consisted of age less than 3 years, patients with sub mucous cleft palate or cleft palate, congenital anomalies, and cervical spine anomalies. We divided the patients into two groups i.e. conventional adenoidectomy (group A) (n₁ = 21) and endoscopic microdebrider assisted adenoidectomy (group B) (n₁ = 21) groups using the lottery method of randomization. After obtaining a written informed consent, we obtained the following data on a printed proforma.

1. History: demographic data, detailed history of chief complaints (nasal obstruction, mouth breathing, snoring, sleep disturbance, middle ear disease, recurrent upper respiratory tract infection), and family history of atopy and bleeding disorders

2. All routine investigations including haemoglobin, bleeding time, clotting time, platelet count, prothrombin time, absolute partial thromboplastin time, X-ray skull soft tissue nasopharynx lateral view

3. Endoscopic assessment of adenoid: after packing the nose with 4% xylocaine with 1:1000 adrenaline soaked cotton patties for 3–4 min, we performed nasal endoscopy with 2.7 mm Hopkins Karl Storz endoscope. The size of the adenoid was graded intra-operatively using Clemens and McMurray grading system [4]. According to this classification,

• grade I has adenoid tissue filling 1/3rd the vertical height of the choana,

• grade II up to 2/3rd the vertical height of the choana,

• grade III from 2/3rd to nearly all but not complete filling of the choana,

• grade IV with complete choanal obstruction.

Both operations were performed under general anesthesia administered via cuffed endotracheal tube placed in the midline of the lower lip. In conventional adenoidectomy technique, patient was prepared in Rose’s position. After adenoidectomy clearance was confirmed intra-operatively by palpation. Haemostasis achieved by packing nasopharynx with pre weighted roller packs after which tonsillectomy was performed wherever indicated. Duration of conventional adenoidectomy was measured from the time patient was handed over to the surgeons by anesthetist after intubation till haemostasis achieved after adenoid resection. Blood loss was measured from suction and weight of blood loss in packed roller pack inside nasopharynx.

Endoscopic microdebrider assisted adenoidectomy technique was performed in supine position. Jaw of the patient was kept open using Boyle Davis mouth gag. The soft palate was first inspected for any defect, and then retracted using catheters or infant feeding tubes that were placed through nasal cavities and retrieved from the oropharynx. This helped to stabilize tonsillar pillars and pulls the uvula out of field. Depending on age of the patient and nasal cavity size, 4 mm or 2.7 mm diameter endoscope was introduced through nasal cavity along with 4 mm Microdebrider blade at 40° vertical through the oral cavity and dissection performed. Adenoids were removed completely under direct vision with endoscope and haemostasis achieved. Duration of the endoscopic procedure was measured similar to that in conventional adenoidectomy group. Endoscopy on follow up was used to look for inadvertent trauma/collateral damage occurred during the procedure and residual adenoid tissue remains at 3 weeks after surgery in patients from both groups.

A comparison between the two groups was made in terms of intra-operative (bleeding, associated trauma to the surrounding tissue, total resection time) and postoperative parameters (postoperative bleeding, infection and other complications).

Sample size of this study was calculated with the help of previously published papers keeping the p value at < 0.05 and power of study at 80%. Results on continuous measurements were presented as mean ± SD (min–max) and categorical measurements presented in number (%). Significance was assessed at 5% level of significance assuming normal distribution of dependent variables and randomization of independent samples. We used two tailed, independent student t test to find the significance of study parameters on continuous scale between two groups. MedCalc Software Version 12.5.0 was used for the analysis of the data and Microsoft Word and Excel have been used for data entry.

Results

In this study total 42 patients were included and they were divided by lottery method in group A (21 patients) (50%) operated with conventional technique and group B (21 patients) (50%) operated by endoscopic microdebrider assisted adenoidectomy. Our study showed that majority of patients (10 patients out of 21) in group A were between 11 and 15 years of age and majority patients (12 patients out of 21) in group B were between 6 and 10 years of age (Table 1). Among 42 patients, 33 (79%) were male and 9 (21%) were female suggestive of male preponderance in the study.

Table 1.

Age distribution of patients

Age range	Group A (n = 21)	Group B (n = 21)
0–5	3 (14.2%)	1 (4.7%)
6–10	6 (28.5%)	12 (57%)
11–15	10 (47.6%)	7 (33.3%)
16–20	2 (9.5%)	1(4.7%)

Majority of patients were having presenting complaints of nasal obstruction (90%), mouth breathing (83%) and snoring (62%). Also 71% of patients were having throat pain with dysphagia.

Out of 42 patients, 7 patients presented with typical adenoid face features of which 4 (19.04%) belonged to group A and 3 (14.28%) were in group B. In our study, 32 (79%) patients out of 42 were operated with combined tonsilloadenoid resection while 7 (15%) patients were operated for adenoidectomy alone. In remaining three patients, one was operated for adenoidectomy along with septoplasty, one with grommet insertion in right CSOM (chronic suppurative otitis media) and one with canal wall down mastoidectomy and type III tympanoplasty. The average operative time in group A was 16.15 min and in group B was 22.9 min with p value < 0.05 (Table 2). Average blood loss in group A was 35.57 ml and in group B was 37.14 ml (Table 3). In group A, 4 (19%) patients developed lip trauma and 3 (14%) injured their gums while in group B, 2 (9.5%) and 4 (19%) patients developed lip and gum trauma respectively. Anterior pillar and uvula were injured in 2 (9.5%) and 1 (5%) patients respectively in group A while no such injury was seen in group B (Table 4). In group A, 1 (4.76%) of 21 patients developed temporary velopharyngeal insufficiency which was relieved after 4 weeks of surgery whereas in group B, 5 (23.8%) patients developed nasal bleed and 2 (9.52%) patients presented with nasal synechiae seen endoscopically (Table 5). Instruments like suction and endoscope used during surgery were responsible for nasal mucosal trauma and consequences like nasal bleed and synechiae.

Table 2.

Average duration of surgery

Type of surgery	Average duration (mean ± standard deviation) (min)
Conventional (group A)	16.15 ± 7.8
Microdebrider (group B)	22.95 ± 8.82

Table 3.

Average blood loss in surgery

Type of surgery	Average blood loss (mean ± standard deviation) (ml)
Conventional (group A)	35.57 ± 11.10
Microdebrider (group B)	37.14 ± 8.02

Table 4.

Intra-operative complications in both groups

Site of trauma	Group A (21)	Group B (21)	Total (n = 42)	p value (chi square test)
Lip	4 (19%)	2 (9.5%)	6 (14%)	0.44
Gums	3 (14%)	4 (19%)	7 (17%)	0.72
Anterior pillar	2 (9.5%)	0	2 (5%)	0.17
Uvula	1 (5%)	0	1 (2%)	0.32

Table 5.

Post-operative complications in both groups

Post operative complications	Group A (21)	Group B (21)	Total (n = 42)
Nasal bleed	1 (5%)	5 (24%)	6 (14%)
Oral bleed	2 (9.5%)	1 (5%)	3 (7%)
Synechiae	0	2 (9.5%)	2 (2%)
Velopharyngeal insufficiency	1 (5%)	0	1 (5%)

Postoperative symptomatic improvement was seen in 18 patients in group A whereas three patients showed persistence of mouth breathing, nasal obstruction and snoring after 3 weeks on follow up. In group B, all patients showed absence of symptoms 3 weeks following surgery. In group A, 8 (38%) patients had residual grade I adenoids after 3 weeks post operatively (Fig. 1). In group B all patients showed complete clearance in nasopharynx area (Fig. 2, Table 6). Three children in group A and two children in group B were not cooperative for telescopic examination under local anesthesia. Patients who were not cooperative for telescopic examination were assessed based on improvement in symptoms.

Fig. 1.

Pre and post operative images of grade 3 adenoids in conventional curettage adenoidectomy

Fig. 2.

Pre and post operative images of grade 3 adenoids in endoscopic microdebrider assisted adenoidectomy

Table 6.

Symptomatic relief and residual tissue at 3 weeks follow-up

Type of surgery	No. of patients with improved symptoms	No. of patients with persistence of symptoms	Total (n = 42)
Conventional	18	3	21
Microdebrider	21	0	21

Discussion

Adenoidectomy is one of the most common surgical procedures performed by otolaryngologists in the paediatric population. However, recurrence rates following adenoidectomy are very high. These are attributed to certain factors like difficult access of adenoids and the non-visualization of adenoids during removal. The use of an endoscope during adenoidectomy has the advantage of visualizing the adenoid tissue as well as the surrounding structures. Direct visualization enables a better removal of the whole adenoid tissue without injuring the other structures like eustachian tube opening and posterior choana.

In our study, the average operative time in group A was 16.15 min and in group B was 22.9 min with p value < 0.05. Though the precise steps of adenoidectomy would only take 4–5 min, we felt that a true assessment of the operative time should include all steps including preparing and setting up of instruments and equipment like endoscopy trolley and microdebrider set up, packing and securing the bleeding and checking for haemostasis. As a result, the time taken in the present series may seem longer than other studies. The increase in the operative time in the microdebrider assisted technique is probably due to time taken for instrumentation and equipment, endoscopic visualization, bit by bit removal of the adenoid tissue and time consuming haemostasis. The increase in time though statistically significant, adds only minimal extra time to the surgery. This by itself is a small difference and may not be an independent factor in influencing the decision to operate using endoscopes. As with any new surgical technique there is a learning curve to endoscopic assisted adenoidectomy. Initially the surgery appears to take more time but our results demonstrate a trend towards decrease in the time of a procedure with experience. A study by Renuka Bradoo et al. [5] in 2009–2010 showed that mean time in conventional adenoidectomy was 9 min and in endoscopic adenoidectomy was 14 min (p < 0.05). The study by Col Datta et al. [6] in 2004–2005 showed that mean time taken in conventional method was 29.3 min. In contrast, in powered endoscopic surgery, the time taken was 39.3 min. The difference in time taken in the two procedures was found to be significant (p < 0.05). This data confirms our finding. In May 2018, Shaweta et al. [7] performed a study which showed similar operative time in both groups with p value > 0.05 which was not significant therefore, not correlated to our study.

Mean blood loss in our study was 35.5 ml in group A and 37.1 ml in group B (p > 0.05) which was similar in both the groups and hence, not significant. In Datta [6] study conventional method showed 21 ml of blood loss while microdebrider method showed 31.67 ml, which was significant (p < 0.05). In Renuka Bradoo study [5]. In conventional adenoidectomy, mean blood loss was 33 cc whereas in endoscopic adenoidectomy, it was 38 cc (p > 0.05). So our study was statistically similar with Bradoo study but not with Datta study. Findings in all these studies suggest higher blood loss in endoscopic method study.

In Datta study, resection was invariably complete by the endoscopic method. Contrary to this, in seven (23%) cases of conventional method, more than 50% adenoid tissue was left behind and in additional nine cases (30%) between 20 and 50% of adenoid tissue was left, which was statistically significant [6]. In our study also 8 (38%) patients in group A shows grade I adenoids after 3 weeks of surgery and complete clearance after endoscopically microdebrider assisted method (p < 0.05). All eight patients operated with conventional method post operatively showed residual adenoidal tissue in the roof and peri-tubal area of the nasopharynx on endoscopic examination. Similar results of Renuka Bradoo study [5] suggest higher incidence of residual adenoid tissue after 3 months of surgery. 14 (87.5%) patients operated with conventional method and 5 (31.2%) patients operated with EA microdebrider method showed residual adenoid tissue (p < 0.05) in Renuka Bradoo study.

A meta-analysis was performed by Liyun Yang et al. [8] in 2016 to analyze the data for total operative time, blood loss and complications. Compared with conventional curettage adenoidectomy, endoscopic assisted adenoidectomy had a shorter operative time (p < 0.00001), less blood loss (p < 0.00001), and fewer complications (p < 0.0001). Hence, endoscopic assisted adenoidectomy has advantages over conventional curettage adenoidectomy with regard to total operative time, blood loss and complications. Our study does not correlate with this study.

Another study by Costantini et al. [9] demonstrated that endoscopic technique is characterised by a high level of precision and a very low incidence of post-operative bleeding. The precision offered by the improved visual field of the endoscope combined with the extreme manageability of the microdebrider allows the surgeon to control the efficient removal of the adenoid tissue, to the great advantage of the patient. The main limitation of microdebrider includes high cost of the devise, the replacement cost of blades and lack of resected tissue for histopathological examination.

Conclusion

Endoscopic microdebrider assisted adenoidectomy is accurate and precise as compared to conventional technique for complete removal of adenoid tissue under direct vision with no residual tissue left with least chances of trauma to the surrounding structures. Conventional adenoidectomy has less intra-operative blood loss and shorter surgical time duration as compared to endoscopic assisted microdebrider adenoidectomy but with higher chances of residual adenoid tissue. Thus endoscopic assisted powered adenoidectomy needs to be acknowledged as a safe alternate to conventional adenoidectomy.

Compliance with Ethical Standards

Conflict of interest

All the authors declare that they have no conflict of interest in the submission of this manuscript.

Ethical Approval

All procedures performed in the studies involving human participant were in accordance with the ethical standards of the institutional research committee and ethical standards.

Human and Animal Rights

This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.