Clinical outcomes of endoscopy assisted conventional adenoidectomy and endoscopic adenoidectomy with microdebrider: a prospective randomized control study

INTRODUCTION

Adenoidectomy is surgical removal of adenoids or nasopharyngeal tonsils. Whether conducted independently or in conjunction with tonsillectomy or myringotomy, adenoidectomy ranks among the most frequently performed surgeries in paediatric ENT practice.¹ Adenoidectomy is an effective treatment for various conditions, including paediatric sleep-disordered breathing, middle ear pathologies, chronic rhinosinusitis and recurrent adenotonsillitis.² Conventional adenoidectomy is age old practice, performed using an adenoid curette, relies on palpation rather than vision, leading to potential disadvantages such as incomplete removal of adenoid tissue and injuries to surrounding structures like medial end of Eustachian tube, soft palate, anterior atlantooccipital ligament, and aberrant internal carotid artery in rare instances.^3-5 With the advent of endoscopes, its use in adenoidectomy has been popularized and is considered a natural progression of endoscopic technology for a more complete removal of adenoids.⁶ This study intended to evaluate whether the addition of endoscopic visualization to conventional curettage alone can improve clinical outcomes, or whether use of a more advanced ablative device i.e. microdebrider alongside the endoscope is necessary to achieve the best possible clinical outcomes.

METHODS

This is a prospective parallel design comparative randomised control study, conducted from December 2012 to January 2015 at a general tertiary care centre after IEC approval (Ref: BJMC/IEC/Pharmac/D1112093-26 date 27/11/2012). Consecutive patients scheduled for adenoidectomy with indications of sleep disordered breathing (SDB) and/or OME willing to participate and provide consent were included in the study. Patients with bleeding disorders/coagulopathies, submucous cleft palate, acute pharyngeal infections, asymptomatic adenoidal hypertrophy or residual symptomatic adenoids after previous adenoidectomy were excluded from the study. Patients were randomized in 1:1 fashion to either EACCA arm or EAM arm. Surgical intervention performed as per study protocol. Demographic, clinical, intra-operative, postoperative and follow up data recorded prospectively. All patients underwent preoperative lateral skull soft tissue radiograph for gross assessment of nasopharyngeal soft tissue.^7,8 Preoperative middle ear otoscopy and tympanometry was performed to document baseline middle ear status. Paediatric sleep questionnaire was used to asses sleep disordered breathing.^9,10 Score of 0.33 i. e., answering 33% questions positively was taken as sleep disordered breathing. Consort guidelines were used for reporting of the study.¹¹ Study was performed in accordance with declaration of Helsinki, 2013 amendment.

Surgical procedure

Adenoidectomy was performed under general aesthesia, orotracheal intubation. And patient in supine position. Diagnostic nasal endoscopy was performed with 2.9 mm paediatric rigid endoscope (Figure 1a), adenoid enlargement is graded with Clemens and McMurray grading in all cases.¹² Eustachian tube occlusion with peritubal adenoid tissue documented separately. Surgical intervention in both arms performed as described below.

EACCA

Primary surgeon stands at head end of patient. Assistant surgeon standing by side of patient, inserts 0⁰ rigid nasal endoscope. Primary surgeon inserts adenoid curette perorally in the nasopharynx under endoscopic guidance to reach upper edge of adenoid. Now endoscope is removed, neck is gently flexed, adenoid curette is held like a dagger, and adenoid tissue is scraped with back to front swiping movement of curette. Peroral postnasal packing was done for haemostasis. After pack removal, nasopharynx visualised with endoscope to look for residual adenoid tissue. Curettage repeated not more than thrice to remove residual tissue if any and findings documented at the end of procedure.

EAM

Nasal decongestion achieved by nasal packing with cotton pledgets soaked in 4% lidocaine with 1:1000 adrenaline.¹³ Under endoscopic vision microdebrider shaver cannula with suction irrigation aid (60 degree, with debrider tip along concave border) is inserted perorally into nasopharynx (Figure 1b). Adenoid tissue is shaved off under endoscopic vision with debrider at speed <1500 rpm in front to back fashion till perimysium is reached (Figure 1c). Peroral nasopharyngeal packing done for haemostasis. If any bleeding point is observed after pack removal, then controlled with precise electrocoagulation with bayonet bipolar cautery inserted via opposite nostril. Findings documented at the end of procedure.

Intraoperative assessment

Operative time calculated from handing over of case by anaesthesiologist to handing case back to anaesthesiologist. Time for haemostasis is calculated as completion of adenoidectomy to handing over of case to anaesthesiologist for reversal when only adenoidectomy is performed, and handing over to proceed with tonsillectomy. Bleeding is calculated in EACCA arm by calculating difference in the weight of dry and soaked tape gauze. Bleeding in EAM arm calculated by measuring amount of fluid in suction drain and subtracting with amount of saline wash used in addition to weight of tape gauze. Site of residual tissue documented at the end of procedure in both arms.

Postoperative assessment

Pain scores were recorded in postoperative period with Wong and Baker visual scale during anaesthesia recovery period.^14,15 All patients received perioperative antibiotics, antihistaminic and topical decongestants. Hospital stay is calculated from day of surgery to discharge. If patient is readmitted within 30 days of surgery, then number of days are added as hospital stay.

Follow up

All patients were followed up at 1 week, 1 month and 2-month interval post-surgery. Otoscopy, nasal endoscopy, tympanometry, and sleep questionnaire was documented at 2 months follow up to be compared with preoperative status to assess clinical efficacy. Change in the tympanogram from type B to type A was taken as improvement in OME and type A or B to B or C was taken as worsening or no improvement of OME in at least one ear.

Statistical analysis

Sample size was calculated using Cochran’s formula.¹⁶ Quantitative data was analysed using frequencies and measures of central tendencies. Statistical significance for parametric data was assessed using 2-sided Chi-squared and Fisher Exact tests, and Kruskal Wallis and Mann Whitney tests for non-parametric data. P<0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 25@ (IBM, New York, USA). CONSORT guidelines were followed while conducting and reporting the study.¹¹

RESULTS

The study flow is summarized in the CONSORT diagram (Figure 2). Based on eligibility criteria, 90 patients were screened for the study, out of which 37 were excluded. A total of 53 patients were randomized: 27 patients in EACCA arm and 26 EAM arm. All patients underwent surgical intervention as per protocol. Three patients were lost to follow-up at 2 months and thus were excluded from analysis. A total of 50 patients were analysed, of which 23 were males and 27 were females. Patient demographics are summarized in Table 1. Average age was 6.64 (Range 5-13) years. Out of the total patients, 8 experienced sleep disordered breathing as their main complaint, 10 had OME as their main issue, and 32 patients had both conditions concurrently.

Average duration of surgery in EACCA group was 14.43 min whereas in EAM group was 19.09 min, and the difference was not statistically significant. Average blood loss in EACCA group was 84 ml and in EAM group was 96.61 ml and was not statistically significant. All patients in EACCA group had residual tissue with 21/25 (84%) having residual tissue at medial end of eustachian tube. None of EAM group had residual tissue. Injury to medial end of eustachian tube was evident in 7/25 (28%) patients in EACCA group whereas none in EAM group had eustachian tube injury. During follow up, 4 patients in EACCA arm had resolution of residual tissue at sites other than medial end of eustachian tube. All patients in both arms showed improvement in SDB symptoms. Improvement in OME as evident by tympanogram change from type B/C to type A was seen only in 1/19 (7.69%) patient of EACCA arm whereas 21/22 (94.73%) patients in EAM arm showed improvement which was statistically significant.

DISCUSSION

Conventional adenoidectomy with a curette itself is a blind procedure, which relies on palpation and is associated with limitations of residual tissue and injury to surrounding structures. These problems can be partially addressed with use of rigid endoscope. We performed post curettage endoscopy to visualise residual tissue, which was seen in all patients of EACCA. Despite visualising residual tissue, repeat curettage cannot effectively target peritubal area tissue, due to limited reach of the curette. In attempt to angulate the curette laterally and scrape remnant adenoids in peritubal area, medial end of eustachian tube gets injured as evident by our study. This peritubal residual tissue leads to persistence of OME. Canon et al popularised use of endoscope in adenoidectomy. They used 4 mm 0⁰ endoscope transnasally to visualise residual tissue after transoral adenoidectomy and reported invariable presence of residual tissue after conventional adenoidectomy.⁶ They used paediatric pituitary forceps under endoscopic guidance to remove residual tissue and not the adenoid curette, emphasising the fact that additional instrumentation to conventional curette is needed for complete removal of adenoids. Regmi et al used rigid endoscope for visualisation of remnant adenoid tissue and found residual tissue at eustachian tube opening in 63% cases.¹⁸ They reported that subsequent visualisation with endoscope could remove residual tissue from all nasopharyngeal sites except medial end of eustachian tube. Elnasher et al used endoscope to visualise and objectively quantify residual adenoid tissue after conventional adenoidectomy and reported substantial residual tissue left behind after conventional adenoidectomy.¹⁹ Findings of our study coincide with available literature.

We have observed that the visualization of the nasopharynx using an endoscope is comfortably feasible only before and after a conventional adenoidectomy procedure and not while performing curettage. In order to perform a nasal endoscopy, the patient is placed in a supine head elevated position while the surgeon stands on the side of the patient. During adenoid curettage, surgeon has to position himself at the head end of the patient and carries out the procedure while gently flexing and stabilizing the patient's neck with their other hand. This precautionary measure is taken to reduce cervical lordosis, to prevent potential injury to the anterior longitudinal ligament, which could result in Grisel syndrome.^20-22 The concurrent use of an endoscope while doing curettage mandates need of assistant surgeon to hold endoscope. Moreover, with neck flexion, long axis of the endoscope-camera unit collides with the patient's chest, potentially resulting in wear and tear of endoscope-camera unit and also interferes with dagger like movements of curette. It is difficult to effectively coordinate the procedure due to the positioning of the surgeons, patient, and endoscopy unit, which potentially increases surgical duration. Similar findings are noted in study by El-Badrawy et al who simultaneously used 70⁰ rigid endoscope tranorally with curette and reported limitation of unacquainted transoral view and increases wear and tear of endoscope.²³ Bradoo et al performed curettage under endoscopic vision, however they did not describe technical specifications of simultaneous use of endoscope and curette.²⁴ Based on our study, we emphasise technical limitations of concurrent use of endoscope while performing conventional curettage.

Microdebrider can be comfortably used with endoscope in a supine head elevated position. Endoscope is inserted transnasally and microdebrider 60⁰ curved blade with tip on concave side is inserted tranorally which easily reaches nasopharynx up to tubal tonsils, compared to adenoid curette. Microdebrider is powered with suction which sucks adenoid tissue into the tip and safely shaves of every bit of adenoid tissue in back to front fashion under constant vision of endoscope, minimising injury to surrounding structures. Irrigation and suction aids of microdebrider clear blood and tissue bits effectively to provide unhampered vision. Shiny perimysium of superior constrictor can be easily identified which is posterior limit of adenoidectomy. According to our study, EAM could achieve significant tissue clearance compared to EACCA pertaining to technical superiority (Figure 2).

Koltai et al who pioneered use of microdebrider for adenoidectomy, compared outcomes of microdebrider with conventional adenoidectomy in a retrospective study and reported significant less operative time with insignificant difference in the blood loss and hospital stay.²⁵ However, they used no. 5 laryngeal mirror and not endoscope. Stanislaw et al from same group confirmed these findings prospectively, again visualisation was with laryngeal mirror and concluded powered adenoidectomy is significantly faster, with less blood loss, more complete resection and greater surgeon satisfaction.²⁶ Saibene et al did retrospective analysis of 1006 patients treated with endoscopic adenoidectomy with 400 curved blade microdebrider and concluded that endoscopic adenoidectomy requires more operative time but is associated with lesser blood loss, less complications and less treatment failures.²⁷ Somani et al prospectively studied 34 patients and concluded that EAM is a secure and efficient procedure.²⁸ They found no cases of eustachian tube stenosis at the one-year follow-up. However, they also highlighted several drawbacks including cost, limited availability of tissue for histopathology, difficulties in manoeuvring, and a learning curve associated with the procedure. In a systematic review and metanalysis of 17 prospective randomised Studies comparing conventional and other powered adenoidectomy techniques, by Malas et al no statistically significant difference was found in blood loss and operative time.²⁹ Interventional groups other than conventional group had 97% less likelihood of having residual tissue, which was significant. Individual studies comparing perioperative morbidity and outcomes of conventional and powered technique, have been summarised in Table 3. Considering perioperative morbidity; we did not find statistically significant difference in operative time, time required for haemostasis, blood loss, pain score and hospital stay, which is more or less in accordance with the available literature. Suction irrigation aided microdebrider blade with 60⁰ angulation and front facing tip (i.e. along concave border), combined with transnasal 0⁰ endoscope for visualisation provides technical superiority in complete, precise and safe adenoidectomy without perioperative morbidity.

Studies have reported completeness of surgical resection of adenoids, but whether this translates into symptomatic relief at follow up has not been documented in majority of studies. Bradoo et al reported a prospective randomised study of 32 patients comparing conventional adenoidectomy with endoscope assisted adenoidectomy with conventional curette and reported near complete removal of adenoid tissue with endoscopic assistance.²⁴ As per their study, minimal residual adenoid tissue may not have immediate clinical implications, but may regrow to become symptomatic later on. In contrast to the aforementioned study, our study indicates that the presence of residual tissue at the eustachian tube opening is associated with the persistent OME. We compared follow up findings at 2 months with preoperative findings to see the clinical efficacy. Adequate improvement in symptoms of SDB were noted in both arms as central part of adenoids is adequately removed. As described earlier, residual peritubal tissue in EACCA arm translated into persistent OME at follow up. Injury to medial end of eustachian tube explains worsening of OME in EACCA arm possibly due to post traumatic scarring. Major limitation of powered microdebrider is availability of the equipment, recurring cost of blades and learning curve. Based on our study, we suggest conventional adenoidectomy coupled with endoscopes can be effectively used in symptoms of SDB, if cost is a constraint. But considering long term sequalae and associated cost for treatment of OME, EAM is strongly advocated.

Strength and weaknesses of study (SWOT analysis)

The study's strength lies in its prospective randomised design, enabling real-time data collection from consecutive patients. Precise selection criteria were used which can be directly attributed to adenoid enlargement and can be compared objectively for efficacy of the treatment during follow up period. Conducted in a general hospital, the study provides a representative sample of the general population. Sleep disordered breathing needs sleep study for accurate diagnosis and documentation. Due to non-availability, questionnaire-based assessment of sleep disordered breathing was performed, which is a limitation of the study.

CONCLUSION

Clinical efficacy of endoscopic adenoidectomy with a powered microdebrider surpasses that of endoscope assisted conventional curettage. Conventional curettage adenoidectomy, in spite of endoscopic assistance, may still result in the presence of residual tissue especially at medial end of eustachian tube which translates into persistent symptoms of OME in long term. Both techniques however provide effective resolution of symptoms of sleep disordered breathing. Considering cost of powered instrument, if adenoidectomy is indicated only for sleep disordered breathing, then endoscope assisted conventional curettage method is advocated. But if indication is OME, then endoscopic powered adenoidectomy should be preferred, considering long term sequalae of OME.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee approval (Ref: BJMC/IEC/Pharmac/D1112093-26 date 27/11/2012).

REFERENCES

1. 1. Paradise JL, Rogers KD, Bluestone CD, Taylor FH. Efficacy of Adenoidectomy in Recurrent Otitis Media. Ann Otol Rhinol Laryngol. 1980;89(3):319-21.
2. 2. Paradise JL. Efficacy of Adenoidectomy for Recurrent Otitis Media in Children Previously Treated with Tympanostomy-Tube Placement. JAMA. 1990;263(15):2066.
3. 3. McKenzie W, Woolf CI. Carotid Abnormalities and Adenoid Surgery. J Laryngol Otol. 1959;73(9):596-602.
4. 4. Carmack JW. Aberrant internal carotids and their relation to surgery of the pharynx. Laryngoscope. 1929;39(11):707-20.
5. 5. Mohiuddin IM, Burud S, Vats M, Vats D. Preventing the Catastrophe: Aberrant Carotid in Adenoid and Tonsil Surgery: Two Case Reports. New Emirates Med J. 2022;3(1):97-101.
6. 6. Uçar C. Endoscopic adenoidectomy. Kulak Burun Bogaz Ihtis Derg. 2008;18(2):66-8.
7. 7. Yang L, Shan Y, Wang S, Cai C, Zhang H. Endoscopic assisted adenoidectomy versus conventional curettage adenoidectomy: a meta-analysis of randomized controlled trials. Springerplus. 2016;5(1):426.
8. 8. Fujioka M, Young LW, Girdany BR. Radiographic Evaluation of Adenoidal Size in Children: Adenoidal-Nasopharyngeal Ratio. AJR Am J Roentgenol. 1979;133(3):401-4.
9. 9. Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric Sleep Questionnaire (PSQ): Validity and Reliability of Scales for Sleep-Disordered Breathing, Snoring, Sleepiness, and Behavioral Problems. Sleep Med. 2000;1(1):21-32.
10. 10. Chervin RD, Weatherly RA, Garetz SL, Deborah LR, Bruno JG, Elise KH, et al. Pediatric Sleep Questionnaire Prediction of Sleep Apnea and Outcomes. 2007;133(3):216-22.
11. 11. Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMC Med. 2010;8:18.
12. 12. Clemens J, McMurray JS, Willging JP. Electrocautery versus curette adenoidectomy: comparison of postoperative results. Int J Pediatr Otorhinolaryngol. 1998;43(2):115-22.
13. 13. Kasemsuwan L, Griffiths MV. Lignocaine with adrenaline: is it as effective as cocaine in rhinological practice? Clin Otolaryngol. 1996;21(2):127-9.
14. 14. Garra G, Singer AJ, Taira BR. Validation of the Wong-Baker FACES pain rating scale in pediatric emergency department patients. Academic Emergency Med. 2010;17(1):50-4.
15. 15. Hockenberry MJ WDWM. Wong’s Essentials of Pediatric Nursing. 7th ed. St. Louis, MO: Mosby. 2005.
16. 16. Uakarn C, Chaokromthong K, Sintao N. Sample Size Estimation using Yamane and Cochran and Krejcie and Morgan and Green Formulas and Cohen Statistical Power Analysis by G*Power and Comparisons. 2021;76-88.
17. 17. Cannon CR, Replogle WH, Schenk MP. Endoscopic‐assisted Adenoidectomy. Otolaryngol Head Neck Surg. 1999;121(6):740-4.
18. 18. Regmi D, Mathur NN, Bhattarai M. Rigid endoscopic evaluation of conventional curettage adenoidectomy. J Laryngol Otol. 2011;125(1):53-8.
19. 19. Elnashar I, El-Anwar MW, Basha WM, AlShawadfy M. Objective assessment of endoscopy assisted adenoidectomy. Int J Pediatr Otorhinolaryngol. 2014;78(8):1239-42.
20. 20. Al-driweesh T, Altheyab F, Alenezi M, Alanazy S, Aldrees T. Grisel’s syndrome post otolaryngology procedures: A systematic review. Int J Pediatr Otorhinolaryngol. 2020;137:110225.
21. 21. Battiata AP, Pazos G. Grisel’s syndrome: the two-hit hypothesis--a case report and literature review. Ear Nose Throat J. 2004;83(8):553-5.
22. 22. Andreoli S, Josephson GD. Tonsillectomy and Adenoidectomy: Current Techniques and Outcomes. Int J Head Neck Surg. 2016;7(2):104-8.
23. 23. El-Badrawy A, Abdel-Aziz M. Transoral Endoscopic Adenoidectomy. Int J Otolaryngol. 2009;2009:1-4.
24. 24. Bradoo RA, Modi RR, Joshi AA, Wahane V. Comparison of endoscopic-assisted adenoidectomy with conventional method. Clin Rhinol. 2011;4(2):75-8.
25. 25. Koltai PJ, Kalathia AS, Stanislaw P, Heras HA. Power-Assisted Adenoidectomy. Arch Otolaryngol Head Neck Surg. 1997;123(7):685-8.
26. 26. Stanislaw P, Koltai PJ, Feustel PJ. Comparison of Power-Assisted Adenoidectomy vs Adenoid Curette Adenoidectomy. Arch Otolaryngol Head Neck Surg. 2000;126(7):845.
27. 27. Saibene AM, Rosso C, Pipolo C, Paolo L, Alberto S, Filippo G, et al. Endoscopic adenoidectomy: A systematic analysis of outcomes and complications in 1006 patients. Acta Otorhinolaryngologica Italica. 2020;40(1):79-86.
28. 28. Somani SS, Naik CS, Bangad S V. Endoscopic Adenoidectomy with Microdebrider. Indian J Otolaryngol Head Neck Surg. 2010;62(4):427-31.
29. 29. Malas M, Althobaiti AA, Sindi A, Bukhari AF, Zawawi F. Comparison of the efficacy and safety of conventional curettage adenoidectomy with those of other adenoidectomy surgical techniques: A systematic review and network meta-analysis. J Otolaryngol Head Neck Surg. 2023;52:21.
30. 30. Datta R, Singh VP, Deshpal. Conventional versus endoscopic powered adenoidectomy: A comparative study. Med J Armed Forces India. 2009;65(4):308-12.
31. 31. Hussein A I, AL-Juboori S. Conventional Versus Endoscopic-Assisted Adenoidectomy: A comparative Study. Med J Babylon. 2012;9(3):570-82.
32. 32. Ravishakar C, Killera S. Comparing endoscopic microdebrider assisted adenoidectomy with curettage procedure. Int J Otorhinolaryngol Head Neck Surg. 2018;4(2):559.
33. 33. Juneja R, Meher R, Raj A, Rathore P, Wadhwa V, Arora N. Endoscopic assisted powered adenoidectomy versus conventional adenoidectomy- a randomised controlled trial. J Laryngol Otol. 2019;133(4):289-93.
34. 34. Atilla MH, Kaytez SK, Kesici GG, Baştimur S, Tuncer S. Comparison between curettage adenoidectomy and endoscopic-assisted microdebrider adenoidectomy in terms of Eustachian tube dysfunction. Braz J Otorhinolaryngol. 2020;86(1):38-43.
35. 35. Singh S, Prasad B. Comparative Analysis of Conventional Curettage Adenoidectomy with Endoscopic Microdebrider Assisted Adenoidectomy. IOSR J Dental Med Sci. 2020;19:57-60.
36. 36. Harugop A S. Efficacy and Safety of Microdebridern Assisted adenoidectomy over Conventional Adenoidectomy. Bengal J Otolaryngol Head Neck Surg. 2020;28(1):59-66.
37. 37. Taha El-Bahrawy A, Abd-Elshakour Mohammed K, Muftah Emhemmed Yadam A, Elsayed Abdel Bary M, Author C. Comparison between Endoscopic Microdebrider Adenoidectomy and Conventional Curettage Method. 2021;85.
38. 38. Manhas M, Deva FAL, Sharma S. Endoscopic Adenoidectomy Replacing the Outdated Curette Adenoidectomy: Comparison of the Two Methods at a Tertiary Care Centre. Indian J Otolaryngol Head Neck Surg. 2022;74(S3):4788-94.
39. 39. Wadia J, Dabholkar Y. Comparison of Conventional Curettage Adenoidectomy Versus Endoscopic Powered Adenoidectomy: A Randomised Single-Blind Study. Indian J Otolaryngol Head Neck Surg. 2022;74(S2):1044-9.
40. 40. Beemrote DS, Aseri Y, Rawat DS, Mahich S, Verma PC. A Comparative Study of Endoscopic Assisted Powered Adenoidectomy Versus Conventional Adenoidectomy. Indian J Otolaryngol Head Neck Surg. 2023;75(3):1598-603.
41. 41. Yanılmaz M, Akduman D. A comparative study of two adenoidectomy technics for efficacy and safety: Conventional curettage adenoidectomy versus endoscopic microdebrider adenoidectomy. Am J Otolaryngol. 2023;44(4):103807.
42. 42. Raj A, Saldanha M, Kalam AS, Aroor R, Kamath SD. Conventional Adenoidectomy versus Endoscope-Assisted Adenoidectomy: Comparative Study. J Health Allied Sci NU. 2024;76(6):5154-69.