Role of endoscopic nasal examination in reduction of nasopharyngeal adenoid recurrence rates

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Abstract

Objectives

To evaluate the benefit of endoscopic examination after adenoidectomy in detecting residual adenoid tissue that would need completion surgery, in ultimate aim to reduce rates of adenoid recurrence.

Methods

A total of 312 children were included in the study conducted at Ain-Shams University Hospital from January till December 2007, following routine adenoidectomy, 118 had a nasal and nasopharyngeal rigid fiberoptic examination and 194 did not, randomly according to the surgical subunit that performed the surgery. Patients were followed up for a minimum of 2 years for recurrence of symptoms of adenoid enlargement.

Results

Endoscopic examination revealed that 14.5% of patients undergoing adenoidectomy had residual adenoid tissue that needed further removal, of these the most common site was at the lateral walls of the nasopharynx (47%). The recurrence rate of adenoid hypertrophy needing re-surgery with endoscopic examination (0.85%) approaches that of the lowest recorded (0.5%) with more expensive and costly methods, and statistically significant lower than rates when endoscopy is not performed (5.6%). Additional time needed for such examination was negligible in terms of cost–benefit relationship.

Conclusion

Rigid fiberoptic endoscopy of the posterior choana and nasopharynx at the end of adenoidectomy provides the benefit of detecting unremoved adenoid tissue without significantly extra cost, time, nor expertise, and helps reduce significantly the rates of recurrence of adenoid enlargement, which might be attributed to residual “missed” adenoid tissue.

Introduction

Adenoidectomy is one of the most common worldwide performed otolaryngologic procedures, whether alone or in association with tonsillectomy or ventilation tube insertion, with rates reaching 65 per 10,000 children in England and 50 per 10,000 children in the United States [1]. Although various techniques have been described, the “blind technique” is still widely performed in various countries. There is a recurrence rate with the surgical procedure which no literature has agreed upon, nor even reached comparable incidences, historically, literature shows extreme variations. According to Lundgren, the recurrence rate is 4–8%, in Hill's investigation it was 23.7–50%, Crowe found the recurrence rate of adenoid tissue to be over 75% [2]. More recent studies record markedly lower incidences, reaching down to 0.5% [3], [4], which might be contributed to better techniques. Historically, Tolczynski [2] attributed various causes to recurrence of adenoid enlargement, namely: (1) anatomical difficulties. (2) Though adenoidectomy is regarded as a simple procedure and is carried out by everybody, it is more difficult to perform a clean adenoidectomy than tonsillectomy. Very often remnants will be found where either the casual operator or the qualified otolaryngologist has been satisfied that the operation was complete. (3) Adenoidectomy is often performed in a hurry, and the inadequate anesthesia is responsible for insufficient relaxation of the palato-pharyngeal muscles, whose contracture interferes with the manipulations of the adenoid curette and nasal biting forceps. (4) In many cases it is an “Operation in the dark”.

One of the explanations of such recurrence is “missing” adenoid tissue, especially if there are choanal adenoids, at this site; the adenoid tissue is difficult to access by the regular curette, and is difficult to visualize by the mirror. Tubal tonsillar hyperplasia, as opposed to regrowth of residual adenoid tissue previously removed, accounts for some cases. Extraesophageal reflux is also a possible cause [4].

Endoscopic adenoidectomy has been described by Uçar [6], and it is stated that there is almost zero rate of recurrence, but this procedure is relatively time consuming and costly, in comparison to other methods used.

Section snippets

Aim of the work

We proposed a protocol aiming to reduce the rate of recurrence of adenoid hypertrophy and avoid missing choanal or any residual adenoid tissue by endoscopic examination of BOTH sides of the nose reaching the posterior choana and the nasopharynx, using a 0° Hopkins pediatric sinoscope, at the end of each adenoidectomy, if any adenoid tissue is found residually, it was removed endoscopically, comparing the recurrence rates of adenoid growth with this protocol with the rate of recurrence with

Patients and methods

The study was designed as an individual inception cohort study (level 1b evidence). The study was performed at the Otolaryngology department, Ain-Shams University Hospital, Cairo, Egypt, after approval by the moral and ethical committee of the University, during the period from January to November 2007; it initially included 324 children below the age of 8 years, undergoing adenoidectomy with or without other procedures. Children were randomly divided into a study group (where the children

Results

Of the 122 study group patients, 118 (97%) complied with the study design and were included in the results as the remaining failed to show up at the follow-up periods, and could not be contacted, and of the 202 control patients 194 (96%) completed the study as designed.

From the 118 that completed the study and performed adenoidectomy followed by endoscopic examination (study group), intraoperative endoscopic examination revealed that 17 patients (14.5%) had residual adenoid tissue, and a

Discussion

The fact that revision adenoidectomy rates are decreasing more and more may be contributed to the improvement and refinement of the methods and techniques followed during the procedure itself, and awareness of the surgeons to the possible faults that led to recurrence. Of these faults is leaving residual adenoid tissue in areas less accessible by the conventional “blind technique” still widely used, or less visible by the mirror visualization technique. The most important of these are the

Conclusion

Endoscopic examination of the nasal fossae and posterior choana for residual adenoid tissue at the end of conventional adenoidectomy surgery is warranted and does not add to the time or cost of surgery, nor does it need special expertise, and has the merit of having a significant value in reducing the rates of recurrence of adenoid tissue attributed to missing adenoid tissue during surgery, and is comparable in results to more expensive techniques, as the use of electrocautery adenoidectomy or

References (9)

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