Adenoidectomy

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Adenoidectomy
Gray994-adenoid.png
Location of the adenoid
Specialty Otorhinolaryngology
ICD-9-CM 28
MeSH D000233
MedlinePlus 003011
eMedicine 872216

Adenoidectomy is the surgical removal of the adenoid for reasons which include impaired breathing through the nose, chronic infections, or recurrent earaches. The effectiveness of removing the adenoids in children to improve recurrent nasal symptoms and/or nasal obstruction has not been well studied. [1] The surgery is less commonly performed in adults in whom the adenoid is much smaller and less active than it is in children. It is most often done on an outpatient basis under general anesthesia. Post-operative pain is generally minimal and reduced by icy or cold foods. The procedure is often combined with tonsillectomy (this combination is usually called an "adenotonsillectomy" or "T&A"), for which the recovery time is an estimated 10–14 days, sometimes longer, mostly dependent on age.

Contents

Adenoidectomy is not often performed under one year of age as adenoid function is part of the body's immune system, but its contribution to this decreases progressively beyond this age.

Medical uses

The indications for adenoidectomy are still controversial. [2] [3] [4] Widest agreement surrounds the removal of the adenoid for obstructive sleep apnea, usually combined with tonsillectomy. [5] Even then, it has been observed that a significant percentage of the study population (18%) did not respond. There is also support for adenoidectomy in recurrent otitis media in children previously treated with tympanostomy tubes. [6] Finally, the effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections, common cold, otitis media and moderate nasal obstruction has been questioned with the outcome, [1] in some studies, being no better than watchful waiting. [7] [8]

Frequency

Removed adenoid Adenoide.jpg
Removed adenoid

In 1971, more than one million Americans underwent tonsillectomies and/or adenoidectomies, of which 50,000 consisted of adenoidectomy alone. [9]

By 1996, roughly a half million children underwent some surgery on their adenoid and/or tonsils in both outpatient and inpatient settings. This included approximately 60,000 tonsillectomies, 250,000 combined tonsillectomies and adenoidectomies, and 125,000 adenoidectomies. By 2006, the total number had risen to over 700,000 but when adjusted for population changes, the tonsillectomy "rate" had dropped from 0.62 per thousand children to 0.53 per thousand. A larger decline for combined tonsillectomy and adenoidectomy was noted - from 2.20 per thousand to 1.46. There was no significant change in adenoidectomy rates for chronic infectious reasons (0.25 versus 0.21 per 1000). [10]

History

Adenoidectomy was first performed using a ring forceps through the nasal cavity by William Meyer in 1867. [11]

In the early 1900s, adenoidectomies began to be routinely combined with tonsillectomy. [12] Initially, the procedures were performed by otolaryngologists, general surgeons, and general practitioners but over the past 30 years have been performed almost exclusively by otolaryngologists.

Then, adenoidectomies were performed as treatment of anorexia nervosa, mental retardation, and enuresis or to promote 'good health'. By current standards, these indications seem odd but may be explained by the hypothesis that children might have failed to thrive if they had chronically sore throats or severe obstructive sleep apnea (OSA). Also, children who heard poorly because of chronic otitis media might have had unrecognized speech delay mistaken for intellectual disability. Adenoidectomy might have helped to resolve ear fluid problems, speech delays, and consequent perceptions of low intelligence.

The relationship between enuresis and obstructive apnea, and the benefit of adenoidectomy by implication, is complex and controversial. On one hand, the frequency of enuresis declines as children grow older. On the other, the size of the adenoid, and again by implication, any obstruction that they might be causing, also declines with increasing age. These two factors make it difficult to distinguish the benefits of adenoidectomy from age-related spontaneous improvement. Further, most of the studies in the medical literature which appear to show benefit from adenoidectomy have been case reports or case series. Such studies are prone to unintentional bias. Finally, a recent study of six thousand children has not shown an association between enuresis and obstructive sleep in general but an increase with advancing severity of obstructive sleep apnea, observed only in girls. [13]

A decline in the frequency of the procedure started in the 1930s as its use became controversial. Tonsillitis and adenoiditis requiring surgery became less frequent with the development of antimicrobial agents and a decline in upper respiratory infections among older school-aged children. Also, several studies had shown that adenoidectomy and tonsillectomy were ineffective for many of the indications used at that time as well as the suggestion of an increased risk of developing poliomyelitis after the procedure, later disproved. [14] Prospective clinical trials, performed over the last 2 decades, have redefined the appropriate indications for tonsillectomy and adenoidectomy (T&A), tonsillectomy alone, and adenoidectomy alone. [9]

See also

Related Research Articles

<span class="mw-page-title-main">Otorhinolaryngology</span> Medical specialty of the head and neck

Otorhinolaryngology is a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, head and neck surgeons, or ENT surgeons or physicians. Patients seek treatment from an otorhinolaryngologist for diseases of the ear, nose, throat, base of the skull, head, and neck. These commonly include functional diseases that affect the senses and activities of eating, drinking, speaking, breathing, swallowing, and hearing. In addition, ENT surgery encompasses the surgical management of cancers and benign tumors and reconstruction of the head and neck as well as plastic surgery of the face, scalp, and neck.

<span class="mw-page-title-main">Sleep apnea</span> Disorder involving pauses in breathing during sleep

Sleep apnea is a sleep-related breathing disorder in which repetitive pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor ventilation and sleep disruption. Each pause in breathing can last for a few seconds to a few minutes and occurs many times a night. A choking or snorting sound may occur as breathing resumes. Common symptoms include daytime sleepiness, snoring, and non restorative sleep despite adequate sleep time. Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. It is often a chronic condition.

<span class="mw-page-title-main">Otitis media</span> Inflammation of the middle ear

Otitis media is a group of inflammatory diseases of the middle ear. One of the two main types is acute otitis media (AOM), an infection of rapid onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep. Decreased eating and a fever may also be present. The other main type is otitis media with effusion (OME), typically not associated with symptoms, although occasionally a feeling of fullness is described; it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media. Chronic suppurative otitis media (CSOM) is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks. It may be a complication of acute otitis media. Pain is rarely present. All three types of otitis media may be associated with hearing loss. If children with hearing loss due to OME do not learn sign language, it may affect their ability to learn.

<span class="mw-page-title-main">Palatine tonsil</span> Lymphoid organs at the back of the throat on both sides

Palatine tonsils, commonly called the tonsils and occasionally called the faucial tonsils, are tonsils located on the left and right sides at the back of the throat, which can often be seen as flesh-colored, pinkish lumps. Tonsils only present as "white lumps" if they are inflamed or infected with symptoms of exudates and severe swelling.

<span class="mw-page-title-main">Tonsillectomy</span> Surgical removal of the tonsils

Tonsillectomy is a surgical procedure in which both palatine tonsils are fully removed from the back of the throat. The procedure is mainly performed for recurrent tonsillitis, throat infections and obstructive sleep apnea (OSA). For those with frequent throat infections, surgery results in 0.6 fewer sore throats in the following year, but there is no evidence of long term benefits. In children with OSA, it results in improved quality of life.

<span class="mw-page-title-main">Adenoid</span> Type of tonsil

In anatomy, the pharyngeal tonsil, also known as the nasopharyngeal tonsil or adenoid, is the superior-most of the tonsils. It is a mass of lymphoid tissue located behind the nasal cavity, in the roof and the posterior wall of the nasopharynx, where the nose blends into the throat. In children, it normally forms a soft mound in the roof and back wall of the nasopharynx, just above and behind the uvula.

Upper airway resistance syndrome (UARS) is a sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The symptoms include unrefreshing sleep, fatigue, sleepiness, chronic insomnia, and difficulty concentrating. UARS can be diagnosed by polysomnograms capable of detecting Respiratory Effort-related Arousals. It can be treated with lifestyle changes, functional orthodontics, surgery, mandibular repositioning devices or CPAP therapy. UARS is considered a variant of sleep apnea, although some scientists and doctors believe it to be a distinct disorder.

<span class="mw-page-title-main">Tonsil stones</span> Mineralized debris within the crevices of the tonsils

Tonsil stones, also known as tonsilloliths, are mineralizations of debris within the crevices of the tonsils. When not mineralized, the presence of debris is known as chronic caseous tonsillitis (CCT). Symptoms may include bad breath, foreign body sensation, sore throat, pain or discomfort with swallowing, and cough. Generally there is no pain, though there may be the feeling of something present. The presence of tonsil stones may be otherwise undetectable; however, some people have reported seeing white material in the rear of their throat.

A myringotomy is a surgical procedure in which an incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid, or to drain pus from the middle ear. A tympanostomy tube may be inserted through the eardrum to keep the middle ear aerated for a prolonged time and to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously within two to three weeks. Depending on the type, the tube is either naturally extruded in 6 to 12 months or removed during a minor procedure.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

<span class="mw-page-title-main">Tympanostomy tube</span> Medical device inserted into the eardrum

Tympanostomy tube, also known as a grommet,myringotomy tube, or pressure equalizing tube, is a small tube inserted into the eardrum via a surgical procedure called myringotomy to keep the middle ear aerated for a prolonged period of time, typically to prevent accumulation of fluid in the middle ear. The tube itself is made in a variety of designs, most often shaped like a grommet for short-term use, or with long flanges and sometimes resembling a T-shape for long-term use. Materials used to manufacture the tubes are often made from fluoroplastic or silicone, which have largely replaced the use of metal tubes made from stainless steel, titanium, or gold.

<span class="mw-page-title-main">Uvulopalatopharyngoplasty</span> Surgical procedure

Uvulopalatopharyngoplasty is a surgical procedure or sleep surgery used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may typically be removed include:

<span class="mw-page-title-main">Maxillomandibular advancement</span> Type of jaw surgery

Maxillomandibular advancement (MMA) or orthognathic surgery, also sometimes called bimaxillary advancement (Bi-Max), or maxillomandibular osteotomy (MMO), is a surgical procedure or sleep surgery which moves the upper jaw (maxilla) and the lower jaw (mandible) forward. The procedure was first used to correct deformities of the facial skeleton to include malocclusion. In the late 1970s advancement of the lower jaw was noted to improve sleepiness in three patients. Subsequently, maxillomandibular advancement was used for patients with obstructive sleep apnea.

<span class="mw-page-title-main">Tonsil</span> Lymphoid organs in the mouth and throat

The tonsils are a set of lymphoid organs facing into the aerodigestive tract, which is known as Waldeyer's tonsillar ring and consists of the adenoid tonsil, two tubal tonsils, two palatine tonsils, and the lingual tonsils. These organs play an important role in the immune system.

<span class="mw-page-title-main">Adenoid hypertrophy</span> Enlargement of the adenoid tonsil

Adenoid hypertrophy, also known as enlarged adenoids refers to an enlargement of the adenoid that is linked to nasopharyngeal mechanical blockage and/or chronic inflammation. Adenoid hypertrophy is a characterized by hearing loss, recurrent otitis media, mucopurulent rhinorrhea, chronic mouth breathing, nasal airway obstruction, increased infection susceptibility, and dental malposition.

<span class="mw-page-title-main">Adenoiditis</span> Medical condition

Adenoiditis is the inflammation of the adenoid tissue usually caused by an infection. Adenoiditis is treated using medication or surgical intervention.

<span class="mw-page-title-main">Tympanic membrane retraction</span> Medical condition

Tympanic membrane retraction describes a condition in which a part of the eardrum lies deeper within the ear than its normal position.

Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.

Hyoid suspension, also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure or sleep surgery in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and hypopharyngeal airway. The horseshoe shaped hyoid bone sits directly below the base of tongue with the arms of the bone flanking the airway. Hyoid suspension is typically performed as a treatment for obstructive sleep apnea (OSA). This procedure is frequently performed with a uvulopalatopharyngoplasty (UPPP) which targets sites of obstruction higher in the airway. Typically, a hyoid suspension is considered successful when the patient's apnea-hypopnea index is significantly reduced after surgery.

Transoral robotic surgery (TORS) is a modern surgical technique used to treat tumors of the throat via direct access through the mouth. Transoral robotic sleep apnea (TORSA) surgery utilizes the same approach to open the upper airway of those with obstructive sleep apnea. This technique has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort and precision in remote-access areas.

References

  1. 1 2 van den Aardweg, Maaike Ta; Schilder, Anne Gm; Herkert, Ellen; Boonacker, Chantal Wb; Rovers, Maroeska M. (2010-01-20). "Adenoidectomy for recurrent or chronic nasal symptoms in children". The Cochrane Database of Systematic Reviews. 2010 (1): CD008282. doi:10.1002/14651858.CD008282. ISSN   1469-493X. PMC   7105907 . PMID   20091663.
  2. ↑ Witt, R. L. (June 1989). "The tonsil and adenoid controversy". Delaware Medical Journal. 61 (6): 289–294. ISSN   0011-7781. PMID   2666179.
  3. ↑ McClay, John E (2017-06-20). "Adenoidectomy: Background, History of the Procedure, Epidemiology". Medscape.
  4. ↑ Bluestone, C. D.; Gates, G. A.; Paradise, J. L.; Stool, S. E. (November 1988). "Controversy over tubes and adenoidectomy". The Pediatric Infectious Disease Journal. 7 (11 Suppl): S146–149. doi: 10.1097/00006454-198811001-00005 . ISSN   0891-3668. PMID   3064039. S2CID   71533246.
  5. ↑ Brietzke SE, Gallagher D (June 2006). "The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis". Otolaryngol Head Neck Surg. 134 (6): 979–84. doi:10.1016/j.otohns.2006.02.033. PMID   16730542. S2CID   23177551.
  6. ↑ Paradise JL, Bluestone CD, Rogers KD, et al. (April 1990). "Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement. Results of parallel randomized and nonrandomized trials". JAMA. 263 (15): 2066–73. doi:10.1001/jama.1990.03440150074029. PMID   2181158.
  7. ↑ van den Aardweg MT, Boonacker CW, Rovers MM, Hoes AW, Schilder AG (2011). "Effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections: open randomised controlled trial". BMJ. 343: d5154. doi:10.1136/bmj.d5154. PMC   3167877 . PMID   21896611.
  8. ↑ Rynnel-Dagöö, Britta; Ahlbom, Anders; Schiratzki, Helge (2016-06-28). "Effects of Adenoidectomy". Annals of Otology, Rhinology & Laryngology. 87 (2): 272–278. doi:10.1177/000348947808700223. PMID   646300. S2CID   46456365.
  9. 1 2 "Frequency" . Retrieved 2010-04-06.
  10. ↑ Bhattacharyya N, Lin HW (November 2010). "Changes and consistencies in the epidemiology of pediatric adenotonsillar surgery, 1996–2006". Otolaryngol Head Neck Surg. 143 (5): 680–4. doi: 10.1016/j.otohns.2010.06.918 . PMID   20974339. S2CID   33142532.
  11. ↑ "Tonsillitis, Tonsillectomy, and Adenoidectomy". Archived from the original on 2010-04-20. Retrieved 2010-04-06.
  12. ↑ "Tonsillectomy and Adenoidectomy". Archived from the original on 16 April 2010. Retrieved 2010-04-06.
  13. ↑ Su MS, Li AM, So HK, Au CT, Ho C, Wing YK (August 2011). "Nocturnal enuresis in children: prevalence, correlates, and relationship with obstructive sleep apnea". J. Pediatr. 159 (2): 238–42.e1. doi:10.1016/j.jpeds.2011.01.036. PMID   21397910.
  14. ↑ Miller AH (July 1952). "Incidence of poliomyelitis; the effect of tonsillectomy and other operations on the nose and throat". Calif Med. 77 (1): 19–21. PMC   1521652 . PMID   12978882.
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