Power-Assisted Partial Adenoidectomy

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The Laryngoscope Lippincott Williams & Wilkins, Inc., Philadelphia © 2002 The American Laryngological, Rhinological and Otological Society, Inc.

Power-Assisted Partial Adenoidectomy Kimsey Rodriguez, MD; Nicole Murray, MD; J. Lindhe Guarisco, MD

Objective: To describe partial adenoidectomy using a powered microdebrider and review the experience with the procedure. Study Design: Prospective study and review. Methods: To perform a powerassisted partial adenoidectomy, the surgeon directs the window in the microdebrider blade tip toward the tissue, which is drawn in by suction; the rotating blade then shaves the tissue. Studies have compared this adenoidectomy technique with curette procedures. Results: In a comparative prospective study, we found that operating time and time required for hemostasis were significantly shorter (P ⴝ .001) with power-assisted partial adenoidectomy than with curettage. There was no significant difference between the two procedures in blood loss or complication rate. These results were similar to those of previous studies. Overall, we have performed more than 1000 power-assisted partial adenoidectomies. No longterm complications have occurred, blood loss remains low, and surgeons are satisfied with the technique because of its speed, improved visibility during resection, and precision. Conclusion: We and other authors have found power-assisted partial adenoidectomy to provide a faster, more precise operation than curette techniques, with benefits for both patient and surgeon. Key Words: Adenoidectomy, partial adenoidectomy, microdebrider, power-assisted partial adenoidectomy. Laryngoscope, 112:26 –28, 2002

INTRODUCTION Adenoidectomy is one of the most common surgical procedures performed today, whether performed alone or in conjunction with insertion of pressure equalization tubes or tonsillectomy.1 Indications for adenoidectomy include recurrent adenotonsillitis, chronic otitis media with effusion, upper airway obstruction resulting from tonsillar and adenoidal hypertrophy, and chronic sinusitis in children.2 Complications such as velopharyngeal insufficiency, eustachian tube stenosis, and nasopharyngeal stenosis are uncommon but difficult to resolve once they develop. These problems are best prevented by precise resection of the adenoid tissue with preservation of the integrity of nasopharyngeal structures.

From the Department of Otolaryngology—Head and Neck Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, U.S.A. Send Correspondence to J. Lindhe Guarisco, MD, Department of Otolaryngology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, U.S.A. E-mail: [email protected]

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Curette Adenoidectomy Adenoidectomy is conventionally performed with the curette technique. The patient is placed in the Rose position, a Crowe-Davis mouth gag is inserted and suspended on a Mayo stand, and a red rubber catheter is used to retract the palate. Under indirect mirror visualization, the adenoid pad is removed with several passes of a curette. Remaining tissue at the choana and around the torus tubarius is then resected with smaller curettes, punch forceps, or suction cautery. To prevent velopharyngeal insufficiency, many otolaryngologists routinely perform a partial adenoidectomy (PA), which involves removal of the superior 50% to 80% of the adenoid pad, leaving an inferior tissue remnant undisturbed to ensure adequate velopharyngeal closure. Precision is critical to a successful PA, but it is extremely difficult to leave a symmetric and adequately size adenoid pad just above the Passavant ridge when using curettes. Performing a PA with standard instruments is also timeconsuming and tedious. The need for a faster and more precise technique with a low complication rate prompted development of the power-assisted partial adenoidectomy (PAPA), which is currently the method of choice at the Ochsner Clinic Foundation (New Orleans, LA).

Power-Assisted Partial Adenoidectomy The powered microdebrider (Medtronic Xomed, Inc., Jacksonville, FL) is ideally suited for PAPA. The blade tip (RADenoid, Medtronic Xomed, Inc.) has an outer windowed sheath surrounding an inner rotating blade connected to a standard inline continuous-suction system through the handpiece (Fig. 1). The device is used at a setting of 3000 rpm in the oscillating mode. The surgeon directs the window toward the tissue to be removed; this is drawn in by the vacuum, and the rotating blade then shaves the tissue. The resection begins at the choana and progresses inferiorly with use of a side-to-side motion until the desired amount of adenoid tissue has been removed. At our institution, 20% of the tissue (more in patients in whom the palate is deemed excessively short) is routinely left above the Passavant ridge (Fig. 2). Hemostasis is achieved with suction cautery, which is also used to shape the remaining adenoid tissue into a symmetric ridge just above the superior constrictor muscle.

DISCUSSION Early studies comparing power-assisted adenoidectomy (PAA) with conventional curettage were conducted Rodriguez et al.: Power-Assisted Partial Adenoidectomy

Fig. 2. Partial adenoidectomy using the microdebrider.

TABLE I. Demographic Characteristics, Surgical Indications, and Size of Adenoid Pad in Patients Undergoing Power-Assisted or Curette Partial Adenoidectomy (PA).* Variable

Median age, yrs (range) Sex: M/F Indication for surgery Chronic otitis media Obstruction Tonsillitis Combination Sinusitis Size of adenoid pad Small-moderate Large Very large

Power-assisted PA (n ⫽ 100)

Curette PA (n ⫽ 40)

2 (1–16) 57 (57)/43 (43)

2 (1–16) 17 (43)/23 (57)

61 (61) 28 (28) 4 (4) 4 (4) 3 (3)

15 (37) 12 (30) 4 (10) 9 (23) 0

45 (45) 36 (36) 19 (19)

23 (58) 11 (28) 6 (15)

Fig. 1. Device used for power-assisted partial adenoidectomy. (A) Microdebrider. (B) Cutting blade of microdebrider.

*Values are numbers (%) of total patients in each group unless otherwise indicated.

by Koltai et al.3 and Stanislaw et al.4 and are described in detail elsewhere in this supplement. Briefly, these authors found that PAA was faster and more precise than curettage and had a similar complication rate. The amount of blood loss with PAA was similar to that with curettage in their retrospective study3 but was decreased compared with curettage in their prospective trial.4 From October 1997 to July 1998, we conducted a prospective study in which PAPA (100 patients; Table I) was compared with curette PA (40 patients) with respect to operating time, blood loss, complication rate, and surgeon satisfaction.5 The interval between when the instrument first touched adenoid tissue and completion of the adenoid resection was significantly shorter with PAPA (Table II). The time required for hemostasis was also reduced (Table II), a finding best explained by the greater

ability of the powered microdebrider to provide a precise dissection down to the less vascular fascial plane of tissue. Overall, PAPA resulted in a 59% reduction in total operating time compared with curettage (Table III). We observed no significant difference between the two techniques in blood loss or complication rate. Because of these findings and surgeon satisfaction with PAPA, we concluded that it was the method of choice for PA.

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CONCLUSION Since our study, we have performed more than 1000 PAPA procedures, either alone or in conjunction with other procedures. No long-term complications have occurred, and blood loss remains low (approximately 2 mL/kg body weight). Power-assisted partial adenoidectomy continues to provide a high degree of surgical satisfaction for several Rodriguez et al.: Power-Assisted Partial Adenoidectomy

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TABLE II. Operative Variables for Partial Adenoidectomy (PA) in the Two Study Groups. Variable

Power-assisted PA*

Adenoid removal time (min:sec) Hemostasis time (min:sec) Total operating time (min:sec) EBL (mL) EBL (mL/kg) Complications

0:51 (0:07–5:10) 2:32 (0:52–9:00) 3:22 (1:06–12:45) 35 (10–200) 2.0 (0.4–9.4) None

Curette PA*

3:17 (0:12–14:00) 4:19 (0:50–10:47) 8:11 (1:02–22:00) 48 (5–375) 2.0 (0.3–6.8) None

P value

⬍.001 ⬍.001 ⬍.001 .656 .355

*Values are means (range). EBL ⫽ estimated blood loss.

TABLE III. Total Operating Time Saved with Power-assisted Partial Adenoidectomy, According to Adenoid Size. Adenoid Size

Small-moderate Large Very large All sizes

Time Saved (min:sec)

Time Reduction (%)

3:58 4:16 9:51 4:46

60 56 65 59

reasons other than speed. The inline continuous suction allows improved visibility of structures during resection. The precision of the microdebrider permits complete resection of tissue where desired, while enabling the surgeon to avoid vital structures and excess removal of adenoid tissue inferi-

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orly. The overall result is a faster, more precise operation with benefits for both patient and surgeon.

BIBLIOGRAPHY 1. Bailey BJ, ed. Head Neck Surgery–Otolaryngology, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001: 993–1004. 2. Clement PA, Bluestone CD, Gordts F, et al. Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996. Arch Otolaryngol Head Neck Surg 1998;124:31–34. 3. Koltai PJ, Kalathia AS, Stanislaw P, Heras HA. Powerassisted adenoidectomy. Arch Otolaryngol Head Neck Surg 1997;123:685– 688. 4. Stanislaw P Jr, Koltai PJ, Fuestel PJ. Comparison of powerassisted adenoidectomy vs adenoid curette adenoidectomy. Arch Otolaryngol Head Neck Surg 2000;126:845– 849. 5. Murray NL, Fitzpatrick P, Guarisco JL. Powered partial adenoidectomy: a clinical trial. Arch Otolaryngol Head Neck Surg (in press).

Rodriguez et al.: Power-Assisted Partial Adenoidectomy

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