Tuesday, December 28, 2010

Adenoidectomy

Adenoidectomy may be indicated alone or in combination
with tonsillectomy. In the latter event, adeno ids are
removed first and the nasopharynx packed before sta rting
tonsillectomy.
Indications
1. Adeno id hypertrophy causing snor in g, mouth
breathing, sleep apnoea syndrome or speech abnormaliti
es, i.e. (rhino lalia clausa).
2. Recurrent rhinosinusitis.
3. Chronic secretory otitis media associated with adenoid
hype rplas ia.
4. Recurrent ear discharge in benign CSOM associated
with adeno iditis/adenoid hyperplasia.
5. Dental malocclusion. Adenoidectomy does not correct
dental abnormalities but will prevenr its recurrence
after orthodontic treatment.
Contraindications
1. Cleft palate or submucous palate. Removal of adenoids
causes velopharyngeal insufficiency in such cases.
2. Haemorrhagic diathesis.
3. Acute infection of upper respiratory tract.
Anaesthesia
A lways general, with ora l endocracheal intubation.
Position
Same as for tonsillectomy. Hyperextension of neck should
always be avoided.
Steps of Operation
1. Boyle-Davis mouth-gag is inserted. Before actual
removal of adenoids, nasopharynx should always be
examined by retracting the soft palate with curved
end of the tongue depressor and by digital pa lpation ,
to confirm the diagnos is, to assess the size of adenoids
mass and to push the lateral adeno id mas:es
towards the midline.
2. Proper size of "adenoid curette with guard" is introduced
into the nasopharynx till its free edge touches
the posterior border of nasal septum and is then
pressed backwards to engage the adenoids. At this
level, head shou ld be slightly flexed to avoid injury
to the odontoid process.
3. With gentle sweep ing move ment, adenoids are shaved
off (Fig. 91.1) . Late ral masses are simi larly removed
with smaller curettes; small tags of lymphoid tissue
left behind are removed with punch forceps.4. Haemostasis is achieved by packing the area for
sometime. Persistent bleeders are electrocoagulated
under vision. If bleeding is still not controlled, a
postnasal pack is left for 24 hours.
Endoscopic Adenoidectomy
These days adeno ids can be removed more precisely by
using a debrider under endoscopic concro!.
Post-operative Care
Sdme as in tonsil lectomy. There is no dysphagia and
patient is up and about early.
Complications
l. Haemorrhage, usually seen in immed ia te postoperative
period. Nose and mouth may ' be full of
blood or the only indication may be vomitus of darkcoloured
blood which the patient had been swallowing
gradually in post-operative period. Ri sing pulse
rate is another indicator. Treatment is same as for
per-operat ive haemorrhage. Postnasal pack under
general anaesthesia is often requi red.
2. Injury to eustachian tube opening.
3. Injury to pharyngeal musculature and vertebrae. This is
due to hyperex tension of neck and undue pressure of
curette. Care should be taken when operating patients
of Down's syndrome as 10-20% of them have atlantoaxial
instability.
4. Velophar)lngeal insufficienc)l.
5. Nasopharyngeal stenosis due to scarring.
6. Recurrence. This is due to regrowth of adenoid tissue
left behind.

1 comment:

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