Electrocautery adenoidectomy outcomes: A meta-analysis

Efficacy of Continuous Suctioning in Adenoidectomy Haemostasis-Clinical Study

Introduction: Adenoidectomy is often the first major surgical challenge for the child's haemostatic system, and controlling intraoperative bleeding can be a challenge for the surgeon. Different methods have been used intraoperatively by surgeons in order to enhance haemostasis. The cold air effect (continuous suctioning) has been used by some surgeons during adenoidectomy; however, no documentation of its haemostatic effect has been made. Objectives: Our prospective randomised controlled study enrolled a sample of 140 children undergoing adenoidectomy, and we studied the effect of continuous suctioning on the duration of haemostasis in paediatric adenoidectomy. Materials and Methods: We evaluated the effect of using continuous suctioning during haemostasis at the end of adenoidectomy procedures, comparing variables such as total surgery time, total haemostasis time, and intraoperative blood loss, between two groups: 70 adenoidectomy procedures where no continuous suctioning was used to enhance haemostasis versus the other 70 patients where continuous suctioning was the haemostatic method employed. RESULTS: After statistical analysis of the recorded data, we found that the total duration of adenoidectomy, the duration of haemostasis in adenoidectomy, and the intraoperative blood loss were significantly lower in patients in whom cold air was used for haemostasis. Intraoperative haemostasis failure (and consequent use of electrocautery for haemostasis) was more frequent in patients in whom no suctioning was used; as for the rates of postoperative primary bleeding after adenoidectomy, they were similar in both groups of patients, regardless of the technique used for haemostasis. Conclusions: The use of continuous suctioning during adenoidectomy haemostasis significantly shortens total surgical and haemostasis time, reduces intraoperative blood loss, and reduces the incidence of haemostasis failure (with the consequent need for bipolar electrocautery haemostasis).

Use and Abuse of Electrocautery in Adenoidectomy Hemostasis

Background and objectives: Bipolar electrocautery is commonly used to control bleeding after cold-instrument pediatric adenoidectomy, but the surgeon should be aware of the possible side effects. OBJECTIVE: The aim of our study is to investigate the effects of bipolar electrocautery when used for bleeding control at the end of an adenoidectomy procedure. Materials and Methods: We evaluated the effect of electrocautery on postoperative pain, velopharyngeal insufficiency symptoms, postoperative nasal obstruction, and rhinorrhea in a group of 90 children undergoing adenoidectomy in our ENT department over a period of 3 months. Results: After statistically analyzing the data, we found that the duration of postoperative pain, the duration of rhinorrhea and nasal obstruction, and the duration of painkiller administration, as well as the velopharyngeal insufficiency symptoms, were significantly longer in patients in whom electrocautery was used for hemostasis. A significantly higher incidence of posterior neck pain and halitosis (oral malodor) was noted in the patients in whom electrocautery was used for adenoidectomy hemostasis. Conclusions: Bipolar electrocautery use should be limited during pediatric adenoidectomy hemostasis because of the possible side effects: longer postoperative pain, prolonged nasal obstruction, rhinorrhea and velopharyngeal insufficiency, and halitosis. We noted some side effects that were specific to electrocautery use during adenoidectomy: posterior neck pain and oral malodor. Acknowledging the risk for these symptoms can help to alleviate the anxiety of both the parents and the patients regarding the expected postoperative outcomes.

Comparison Between Different Approaches Applied in Pediatric Adenoidectomy: A Network Meta-Analysis

OBJECTIVE

Adenoidectomy is a surgical procedure most frequently performed by otolaryngologists. However, there are no universally accepted guidelines for the choice of the surgical approach in specific circumstances. Therefore, a network meta-analysis (NMA) is needed to summarize existing studies and provide more evidence-based medical guidelines.

METHODS

A systematic search of the literature was conducted in the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE databases from inception to 31 July 2021. A network meta-analysis of operating time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue was performed.

RESULTS

A total of 20 studies with 2329 patients were included. Four common surgical approaches, including powered vacuum shaver adenoidectomy (PVSA), plasma field ablation adenoidectomy (PFAA), curettage adenoidectomy (CUA), and suction diathermy adenoidectomy (SDA), were compared for operative time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue. There were no significant differences between the surgical techniques for the 3 endpoints, operative time, intraoperative blood loss, and incidence of postoperative residual tissue. The data showed lower postoperative pain scores for PFAA than for CUA (MD = -3.45, 95% CI [-6.01, -0.95]). There were no significant differences in other surgical approaches for postoperative pain scores.

CONCLUSION

There were no significant differences between PVSA, PFAA, CUA, and SDA for operative time, intraoperative blood loss, and incidence of postoperative residual tissue. PFAA had advantages over CUA for postoperative pain scores.

Cold versus hot adenoidectomy: A prospective, randomized controlled trial

OBJECTIVE

Adenoidectomy can be performed using the cold method (mainly adenoid curettes) or the hot method (suction diathermy). Both techniques have similar intra and postoperative outcomes. However, the long-term clinical outcome of improving sleep disorder symptoms has not been well established. The objective of this study was to compare outcomes of hot method and cold method adenoidectomy one year following the surgery.

STUDY DESIGN

A prospective, randomized, single-blinded study of children under age 16 years who underwent adenoidectomy during the years 2014-2017. Patients were randomized to hot or cold adenoidectomy techniques.

SETTING

A tertiary health care referral center.

SUBJECTS AND METHODS

The final analysis included 58 children, mean age 5.9 years (range 1.2-15). The primary outcome was change in the Pediatric Sleep Questionnaire (PSQ) scores one month and one year after surgery. The secondary outcome was complication rate.

RESULTS

Clinical and demographic parameters were similar between the patients in the hot method group (n = 30) and the cold method group (n = 28). Adenoid size and estimated bleeding were similar between the groups. At one month after surgery, PSQ score was improved by a mean + 0.31 in the hot method group compared to +0.32 in the cold method group (p = 0.54). Improvement in PSQ scores was greater following hot than cold adenoidectomy at one year after surgery (+0.31 points vs. +0.22 points, p = 0.009).

CONCLUSION

Hot adenoidectomy is associated with better outcome than the cold technique, as reflected by PSQ scores one year after the surgery.

Comparison of middle ear function and hearing thresholds in children with adenoid hypertrophy after microdebrider and conventional adenoidectomy: a randomised controlled trial

BACKGROUND

Microdebrider has superior efficacy in clearing the adenoids, compared to curettage. We compared the improvement in middle ear function and hearing thresholds after adenoidectomy, by both methods.

MATERIALS AND METHODS

126 patients (median age-9 years) were randomized into groups A and B, where adenoidectomy was done by microdebrider and curettage, respectively. Middle ear function parameters and hearing thresholds were measured serially.

RESULTS

The mean improvement in middle ear pressure, compliance and hearing thresholds were 92.5 ± 67.6 and 84.2 ± 71.4 daPa; (p = 0.40), 0.19 ± 0.34 and 0.27 ± 0.27 mL; (p = 0.07) and 3.20 ± 4.95 and 2.54 ± 3.98 dB; (p = 0.27), in groups A and B, respectively. Reversal of type B tympanograms was noted in both groups.

CONCLUSIONS

Middle ear function and hearing thresholds improved in both groups after adenoidectomy. More improvement was noted in the microdebrider group, which, however, was not significant.

Hot nasal packing with hot saline irrigation for hemostasis after adenoidectomy: A prospective randomized controlled study

OBJECTIVE

This study aimed to investigate the efficacy of hot posterior nasal packing and hot saline irrigation in bleeding control after adenoidectomy.

METHODS

A total of 130 patients scheduled for adenoidectomy were included in the study, and randomized into two groups at the beginning of the surgical operation. After adenoidectomy, saline impregnated tampon, and saline irrigation at room temperature (22 °C) was applied to the patients in one group while 50 °C saline impregnated tampon and saline irrigation at the same temperature were applied to the patients in the other group. We recorded hemostasis for up to 3 min after tamponade for bleeding control, and the amount of bleeding into the nasopharynx.

RESULTS

The age of the patients ranged from 1.5 to 13 years (mean ± SD: 6.07 ± 3.08 years, and 5.33 ± 2.55 years, 22 °C and 50 °C saline irrigation groups, respectively). There were 37 males and 28 females in the 22 °C saline group, while 34 males and 31 females in the 50 °C saline group. When comparing the two groups, there was no statistically significant difference in terms of duration of hemostasis (p = 0.64). However, bleeding scores at 2 nd min after the tamponade were significantly lower in the 50 °C saline group (p = 0.007). The amount of bleeding in the 50 °C saline group was also significantly lower than the 22 °C saline group (p = 0.015).

CONCLUSION

In this study, application of 50 °C saline impregnated tampon, and hot saline irrigation was found to be more effective in the control of bleeding after adenoidectomy by reducing the amount of bleeding compared to 22 °C saline impregnated tampon application and saline irrigation at 22 °C. However, hot nasal packing and hot saline irrigation did not affect duration of hemostasis and cauterization.

3D-structural change of nasopharynx following adenoidectomy: 10-year serial data in a single hospital

PURPOSE

Scar contracture commonly refers to decreased function in the scar area, whereas scar contraction refers to shortening of the scar length compared to the original wound. Wound scar remodeling occurs during months to years of wound healing to form a mature scar. Serial reports about patients who had undergone adenoidectomy are rare. Thus, the objective of this study was to evaluate some parameters of air way passage in patients who had undergone post adenoidectomy.

METHODS

Data of patients who have undergone adenoidectomy between 2000 and 2002 in our hospital were obtained. A total of 154 head and neck CT scans from an adenoidectomy group and a control group were analyzed. We measured lengths of several areas, including the width of posterior wall of nasopharynx, the widest diameter in the upper air way, the length between both Eustachian tubes, the length between both pharyngeal recesses, and the anterior to posterior diameter of the nasopharynx. This study was approved by Institutional Review Board (IRB) of the Department of Otolaryngology Head and Neck Surgery of Catholic University (approval number: UC18RESI0130).

RESULTS

There were significant differences in the following parameters between the two groups: the width of posterior wall of nasopharynx and the length between both pharyngeal recesses.

CONCLUSION

Extensive removal of soft tissue or injured muscle layer during surgery might be one of the reasons for the narrowing of airway. Keeping in mind not to make much injury the soft tissue or muscles during adenoidectomy is very important for the long-term outcome of this surgery.

The Comparison between Microdebrider Assisted Adenoidectomy and Coblation Adenoidectomy: Analyzing the Intraoperative Parameters and Post-operative Recovery

Microdebrider adenoidectomy and Coblation adenoidectomy are the two new techniques available for adenoidectomy these days. The advantages of endoscopic power assisted adenoidectomy over cold steel adenoidectomy has been well established in the literature. As adenoidectomy is one of the most common paediatric surgical procedure there is always a concern to improve the outcomes and make postoperative experience more pleasant for the paediatric population. Cost difference between a coblator wand and microdebrider blade is always a confounding factor in decision making. The present study was conducted to compare both the techniques of adenoidectomy in terms of certain intraoperative and post operative parameters. The present study was a prospective randomized single blind study conducted in a university hospital on 140 subjects. The patients diagnosed with chronic adenoiditis grade 3-4 were randomly allocated in two groups after following the exclusion and inclusion criteria. the adenoidectomy in two groups; Microdebrider group and Coblation group were compared in terms of intraoperative time, post operative pain score; intraoperative bleeding, surgical field and some common complications. The data was analysed for significance by various statistical tests. The average adenoid size operated in both groups was Grade 3. The intraoperative time taken to complete the procedure in group A was 12.78 ± 3.8 min and in group B was 22 ± 3.3 min with p value < 0.05. There was statistically significant difference in grade of Intraoperative Bleeding in both groups with mean grade of intraoperative bleeding being 1.4 ± 1.04 in group B and 3.5 ± 0.9 in Group A. The surgical field was poor to average in 33 cases (n = 70) in group A as compared to only 1 case (n = 70) in group B; the difference being statistically significant. The average post-operative pain score was 2.69 ± 0.99 and 1.17 ± 1.1 after post-operatively 24 h and 72 h respectively in group B; 7.14 ± 0.99 and 4.08 ± 1.42 respectively in group A. The p value for the same was < 0.05. However there was no statistically significant difference between two groups in terms of any complications or completeness of removal. Though both the techniques are highly efficacious in adenoid removal and low complication rate in our study but still more studies with large sample size are encouraged to validate these results and establish the comparative efficacy of both the techniques in terms of the intraoperative parameters as well as post-operative recovery along with recurrence rates.

Halitosis and Pain Post Electrocautery Adenoidectomy

Background and Objectives: Electrocautery adenoidectomy (ECA) is a common procedure performed in paediatric otolaryngology. ECA has been preferred over curettage adenoidectomy due to its lower intraoperative bleeding rates, decreased procedure time, and higher subjective success. However, post-ECA symptoms of pain and halitosis have never been studied. The objective of our study was to identify the pattern of post-ECA halitosis and pain in the paediatric population. Materials and Methods: This is a single centre, prospective observational study that uses visual analogue scales (VAS) by parent proxy to assess post-ECA pain and halitosis in paediatric patients (age < 18) in South Australia. A total of 19 patients were enrolled in the study and followed for seven days. Results: Postoperative pain and halitosis reaches a peak 3 days post-ECA (median = 2 for pain; median = 6 for halitosis) but resolves 7 days post-ECA (median = 0 for both). Conclusions: Our study demonstrates that halitosis and pain occur over a seven-day period in patients undergoing ECA and will resolve post-operatively with simple analgesia and without antibiotics.

The Incidence of Revision Adenoidectomy: A Comparison of four Surgical Techniques over a 10-year Period

Approximately 130,000 adenoidectomies are performed each year in the United States. Few studies have examined adenoid regrowth and the incidence of revision surgery or have compared four different surgical instruments commonly used for adenoid surgery within the same institution. This study aimed to determine the incidence of revision adenoidectomy after the use of microdebrider, Coblation, suction cautery, and curette instruments over a 10-year period at a single major tertiary children's center in the United States. A retrospective chart review was performed for all patients who underwent primary and/or revision adenoidectomy at the Children's Hospital Los Angeles (CHLA) between August 2004 and August 2014. During the 10-year study period, a microdebrider was used in 212 cases, Coblation in 382, suction cautery in 1,926, and curette in 3,139 adenoidectomies. The percentages of revision adenoidectomy were 1.42% (3 patients) for microdebrider, 0.79% (3 patients) for Coblation, 0.36% (7 patients) for suction cautery, and 0.03% (1 patient) for curette. The cumulative incidence of revision adenoidectomy for initial surgeries performed at CHLA was 0.2% for the 10-year study period. Pearson chi-square analysis showed statistically significant differences between the surgical techniques (p < 0.0001). In conclusion, regrowth of adenoid tissue requiring revision surgery occurs very infrequently irrespective of the instrument used for the primary procedure, and the most common indication for revision adenoidectomy is to improve eustachian tube dysfunction rather than nasal obstruction due to adenoid hypertrophy.

Painful torticollis following adenotonsillectomy: a cardinal sign of atlantoaxial subluxation

An 11-year-old boy with a history of autism spectrum disorder attended the emergency department with his mother 8 days after an adenotonsillectomy reporting postoperative bleeding. Detailed physical examination revealed no active bleeding, but a rigid neck posture was noted. A head and neck CT scan demonstrated unilateral rotatory atlantoaxial subluxation and possible damage to the anterior spinal ligament. He was reviewed by neurosurgeons who performed manipulation under anaesthetic and successfully realigned the occipital cervical tract. Non-traumatic atlantoaxial subluxation (Grisel's syndrome) is a rare but serious complication of routine ear, nose and throat (ENT) procedures. An awareness of this complication among paediatricians, otolaryngologists and emergency physicians, and a high index of suspicion in any patient presenting with torticollis following ENT surgery is essential in preventing significant neurological morbidity.

Regrowth of the adenoids after adenoidectomy down to the pharyngobasilar fascial surface

Objectives:

This study aimed to explore adenoid regrowth after transoral power-assisted adenoidectomy down to the pharyngobasilar fascial surface.

Methods:

Transoral adenoidectomy down to the pharyngobasilar fascia surface was performed on 39 patients under endoscopic guidance, using a power-assisted system. The operation time, amount of blood loss and iatrogenic injury, presence of complications, and success and regrowth rates were recorded to assess the feasibility, safety and effectiveness of our surgical technique.

Results:

In this adenoidectomy procedure, the pharyngobasilar fascia was left intact. The estimated blood loss was 5–50 ml (mean 15 ml), and the success rate was 97.3 per cent. Early complications occurred in 2.3 per cent of patients, while no long-term complications occurred in the cohort. No regrowth was found in the follow-up assessments, which were performed for 18–36 months after surgery.

Conclusion:

Adenoid regrowth was rare after adenoidectomy down to the pharyngobasilar fascial surface. The pharyngobasilar fascia can therefore be considered a surgical boundary for adenoidectomy.

Suction diathermy adenoidectomy performed in the district general hospital

BACKGROUND

Adenoidectomy is often carried out in children for conditions such as nasal obstruction, otitis media with effusion, and obstructive sleep apnoea. Traditionally, it is performed as a blind procedure with a St Clair Thomson curette. An acceptable alternative technique is suction diathermy adenoidectomy. This study aimed to ensure that the complication rate of this latter technique was within published rates and national guidelines.

METHOD

A retrospective case note review was conducted, and information regarding surgery, indications and complications was collected.

RESULTS

Post-operative haemorrhage was recorded for 2 of 121 patients (at days 10 and 11 post-operatively): 1 returned to the operating theatre and the other was managed conservatively. Two patients were diagnosed with infection post-operatively and managed with oral antibiotics. A further four patients re-presented with pain; in all cases, this was recorded as secondary to tonsillar fossa infection, rather than being pain related to adenoidectomy.

CONCLUSION

Given the rare but serious potential complications, the authors support National Institute for Health and Clinical Excellence guidance, which recommends that only surgeons with specific training perform this technique. By using the standard procedures for clinical governance, it is possible to ensure safe practice of even little-used techniques.

A Comparison of Revision Adenoidectomy Rates Based on Techniques

Objective

No studies are available specifically comparing revision rates between suction coagulator and microdebrider-performed adenoidectomies. Our objective was to compare revision adenoidectomy rates between these instrument groups.

Study Design

Historical cohort study.

Setting

Patients included in this study had surgery at the Ann and Robert H. Lurie Children’s Hospital in Chicago, Illinois, from June 2007 through December 2011.

Subjects and Methods

The patients were divided into 2 groups based on technique of adenoidectomy used at the time of initial surgery and the regrowth rate analyzed.

Results

During the 4.5-year study period, the microdebrider was used in 4071 adenoidectomies, and 3328 cases were performed with suction coagulation. There was a revision rate of 0.84% (34 patients) for the microdebrider group. The rate was 1.50% (50 patients) for suction coagulation. This difference was found to be statistically significant on univariate analysis. The suction coagulator group had a younger mean age at initial surgery and a higher incidence of gastroesophageal reflux disease. No difference in revision rates between the 2 groups was noted on multivariate analysis.

Conclusion

Symptomatic regrowth of adenoid tissue occurs infrequently. Both suction coagulation and microdebrider methods are commonly used when performing adenoidectomies due to more consistent ease of use in removal of tissue. The incidence of regrowth likely relates to variables other than the technique used, as there was no difference in the regrowth rate between the 2 groups.

The effects of an antistick phospholipid solution on pediatric electrocautery adenoidectomy

We conducted a study to determine if coating a suction cautery tip with an antistick phospholipid solution would decrease the amount of time required to complete primary pediatric adenoidectomies. The aim of the study was focused on two main criteria: the amount of surgical time required to complete each procedure and the number of times an operation had to be interrupted because the suction cautery tip needed to be cleaned (each interruption was called a "handback"). We obtained data prospectively during 61 pediatric adenoidectomies performed at our institution from February through June 2009. These patients were randomized to undergo surgery either with (n = 31) or without (n = 30) the use of the antistick phospholipid solution (Electro Lube; Mectra Labs; Bloomfield, Ind.). The overall mean amount of time needed to complete an adenoidectomy was 6 minutes and 39 seconds (6:39); use of the antistick solution shortened the amount of surgical time by 1:45-a decrease of 23.2% (p = 0.0360). Likewise, surgeries performed with Electro Lube required an average of 3.0 fewer handbacks for cleaning during the operation (p < 0.0001). The benefits of the antistick solution were even more pronounced in patients with larger adenoids than in those with smaller adenoids.

Adenoidectomy Technique in the United Kingdom and Postoperative Hemorrhage

Objective. To investigate the incidence of postoperative hemorrhage and its risk factors after adenotonsillectomy.

Study Design. A prospective cohort study as part of the National Prospective Tonsillectomy Audit.

Setting. National Health Service and private hospitals in England and Northern Ireland.

Subjects and Methods. National Prospective Tonsillectomy Audit methodology was followed with a nonrandomized prospective observational cohort methodology and data collection.

Results. A total of 33,921 patients underwent tonsillectomy; of these, 9900 underwent adjunctive adenoidectomy. Traditional curette adenoidectomy (without any diathermy use at all) was performed in 6871 patients. Suction diathermy technique was used in 1489 patients. Hemorrhage rates were calculated for these main adenoidectomy technique groups and compared by calculation of risk ratios. Both early and late hemorrhage rates for suction diathermy were found to be 0.07% (n = 1 in each case). In the traditional curette group, these rates were 0.3% (n = 19) and 0.2% (n = 14), respectively. The risk ratio for hemorrhage overall was 3.6 for curette adenoidectomy compared with suction diathermy (95% confidence interval, 0.86-14.9; P = .06). The data suggest comparable hemorrhage rates in both adenoidectomy technique groups and fail to demonstrate diathermy usage as a risk factor for hemorrhage following adenoidectomy despite a clear interaction between diathermy usage and subsequent hemorrhage in tonsillectomy.

Conclusion. Use of suction diathermy in adenoidectomy appears to have a similar safety profile to conventional techniques and may offer additional benefits over traditional adenoid curettage. Further clinical and laboratory-based research into the complex interaction between diathermy usage and both adenoid and tonsillar tissue is warranted.

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

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.