Discussion

The last two decades have seen the advent of new adenoidectomy techniques, such as use of the surgical microdebrider, suction diathermy and coblator. Below, we discuss the advantages and disadvantages of these innovations, as well as the need for revision adenoidectomy following each technique.

Bross-Soriano et al. Reference Bross-Soriano, Schimelmitz-Idi and Arrieta-Gómez² evaluated the efficacy of the conventional adenoidectomy technique, using transoperative endoscopic vision of the nasopharynx, and also evaluated the need to include telescopes as part of the standard instrumentation available for adenoidectomy. This study was prospective, comparative and open. It included 150 consecutively recruited patients with an absolute indication for adenoidectomy. These patients underwent 150 adenoidectomy procedures, using conventional technique and Beckman and La Force adenotomes. Once the surgeon considered the procedure to be complete, the authors observed the condition of the nasopharynx (using a laryngeal mirror) and operated adenoid area (using 0° and 30° Hopkins rod telescopes). If any residual adenoids were evident, these were eliminated with Guggenheim forceps, adenotomes or a curved 40° microdebrider tip. Endoscopic visualisation aided in the complete removal of adenoidal tissue and also assisted bleeding control. The authors observed total removal of adenoids in only 43 patients; residual adenoids were found in the remaining 107 cases. Of these cases, 45.3 per cent had adenoidal tissue occluding the pharyngeal part of the both eustachian tubes. Bross-Soriano et al. concluded that conventional adenoidectomy was effective in less than 30 per cent of cases; therefore, they considered the use of endoscopes during every such procedure to be essential.

The clinical importance of adenoidal regrowth or residuum has yet to be clarified. It is now well established that adenoidectomy can be efficacious in the management of otitis media with effusion, in the absence of hyperplasia of the tissue. In our preliminary study,Reference Liapi, Dhanasekar and Turner¹ we found that 1.6 per cent of children who had already undergone adenoidectomy had persistent otological symptoms and required a second operation. This figure undoubtedly underestimated the true rate of recurrence, as some children should have moved to other areas or been referred to other departments, while others would not have sought a specialist opinion even though symptomatic. Furthermore, none of our primary cases underwent formal follow-up nasopharyngeal assessment post-operatively, and we thus relied only on recurrence of symptoms as an indicator of adenoidal regrowth.

Adenoidal regrowth is a poorly understood phenomenon. While parents often express concern regarding the potential for such regrowth, there is little published information about its incidence and causation. However, a study by Monroy et al. Reference Monroy, Behar and Brodsky³ did address this problem, aiming to establish the incidence and possible contributing factors leading to adenoidal regrowth in children. These authors undertook a retrospective case series review within a tertiary care children's hospital. They identified 106 children who had undergone revision adenoidectomy between 1995 and 2006. Thirty-four children were excluded because the primary adenoidectomy had been performed elsewhere or was only partial. In the remaining 72 patients, demographic data, clinical presentation, associated medical conditions and surgical findings were recorded. During the 11-year study period, 13 005 adenoidectomies or adenotonsillectomies were performed; of these, 72/13 005 (0.55 per cent) were revision adenoidectomy procedures. The mean ± standard deviation (SD) for age at presentation was 3.68 ± 2.9 for primary adenoidectomy and 7.69 ± 4.04 years for secondary (revision) adenoidectomy, with an average time interval of 4.3 years between primary and secondary procedures. Age at initial adenoidectomy was not a significant factor in predicting revision adenoid surgery. Of the 72 children who underwent revision adenoidectomy, 29/72 (40 per cent) also underwent reflux investigation, including scintiscan with gastric emptying, 24-hour pH probe testing, or laryngoscopy; 28/29 (96 per cent) were diagnosed with reflux. At least 15 of the 72 children who underwent revision adenoidectomy (21 per cent) were reported to have symptoms consistent with adenoidal regrowth, which was found to be caused by tubal tonsillar hyperplasia. Monroy et al. concluded that revision adenoidectomy is rarely required. Tubal tonsillar hyperplasia, as opposed to regrowth of residual adenoidal tissue after a previous removal procedure, accounts for some cases. The authors also speculated that extra-oesophageal reflux was a possible cause in some cases, and that this required further study.

Hartley et al. Reference Hartley, Papsin and Albert⁴ retrospectively reviewed 410 adenoidectomies undertaken over a 13-month period. A suction diathermy technique was used in 240 cases and conventional curettage in 170. Five patients who haemorrhaged in the post-operative period had undergone traditional curettage. The authors concluded that suction diathermy ablation had the primary advantage of a clear view of the nasopharynx and the adenoids during the actual resection. This allowed controlled removal of adenoid tissue. It also assisted removal of choanal adenoids, which can be present in 10 per cent of children. The clear view during resection also allowed the surgeon to avoid injury to adjacent structures, e.g. eustachian tube orifices. A secondary advantage of suction diathermy ablation was reduced haemorrhage during and after the procedure.

Stanislaw et al. Reference Stanislaw, Koltai and Feustel⁵ compared the safety and efficacy of power-assisted adenoidectomy versus traditional adenoidal curettage adenoidectomy, in a prospective, randomised study within a tertiary care children's hospital. Ninety patients underwent power-assisted adenoidectomy and 87 adenoidal curettage adenoidectomy. The authors evaluated operating time, blood loss, completeness and depth of resection, injury to surrounding structures, short- and long-term complications, surgeon satisfaction with the procedure, and parents' assessment of the patient's post-operative recovery period. The authors concluded that power-assisted adenoidectomy was faster and resulted in less blood loss, more complete resection, better control of resection depth, and greater surgeon satisfaction, compared with traditional adenoidal curettage adenoidectomy.

Shin and HartnickReference Shin and Hartnick⁶ used suction diathermy for adenoid ablation via a solely endoscopic transnasal approach, in an older paediatric population. They found this procedure to be effective and convenient to perform during other transnasal endoscopic procedures. Suction diathermy provided excellent visualisation of both the superior and inferior parts of the nasopharynx, with minimal or no bleeding in the adenoid bed. They encountered no post-operative complications such as bleeding, infection, nasopharyngeal stenosis or velopharyngeal insufficiency. The authors felt that transnasal adenoid ablation was not appropriate for the entire paediatric population, but that it had multiple benefits when another endoscopic, sinonasal procedure was planned, when there was neck instability or when enhanced visualisation of the nasopharynx was desired. The operative time for the endoscopic adenoidectomy procedure, including endoscopic equipment preparation and photo-documentation, was 10–15 minutes. Blood loss was less than 1 ml during the procedure. When adenoidal tissue is left behind following a traditional curettage procedure, it is invariably in the superior half of the nasopharynx. Shin and Hartnick found that an endoscopic, transnasal, suction diathermy procedure avoided this problem; endoscopic visualisation of the superior half of the nasopharynx was excellent. This may be crucial for patients who require adenoidectomy for improvement of nasal airway or middle-ear aeration. Shin and Hartnick concluded that endoscopic transnasal adenoidectomy was relatively safe and effective, with less chance of retaining residual adenoids.

Skilbeck et al. Reference Skilbeck, Tweedie, Lloyd-Thomas and Albert⁷ assessed the use of suction diathermy for adenoidectomy, analysing complications and risk of recurrence. When introduced, suction coagulation was initially utilised for haemorrhage control, following curettage of the adenoid pad. Later, the whole procedure was performed using this technique. Skilbeck and colleagues' study aimed to assess post-operative haemorrhage rates and risk of recurrence following adenoidectomy performed solely by suction diathermy in children. In this retrospective study of 1411 consecutive children, all surgery was performed using suction diathermy. No patients were excluded, and all patients were followed up. No cases of post-operative haemorrhage were encountered. Only 1.7 per cent of patients remained symptomatic and underwent revision adenoidectomy. None required a third procedure. The incidence of regrowth was similar to that reported in patients undergoing conventional adenoidectomy by curettage. The authors suggested suction diathermy as the most appropriate method for adenoidectomy in children.

Skilbeck and colleagues' study found a similar revision adenoidectomy rate (1.7 per cent) to our previous studyReference Liapi, Dhanasekar and Turner¹ (1.6 per cent). Our current study assessed respondents' recognition of the need for revision adenoidectomy as a problem; a total of only 90 consultants (27 per cent (16.2 per cent + 10.8 per cent)) recognised such a need as a problem.

The questionnaire used in the study consisted of mainly closed set questions except for question 4. It is a well recognised fact that the depth or “richness” of the respondents' answers would have greater if open set questions had been used as well. If open set questions had been used this aspect could have been addressed, however the analysis would have been more difficult and would probably require a qualitative approach.