Adenoidectomy

Adenoidectomy
Intervention
Location of the adenoid
ICD-9-CM	28
MeSH	D000233

Adenoidectomy is the surgical removal of the adenoids. They may be removed for several reasons, including impaired breathing through the nose and chronic infections or earaches. The surgery is less common for adults. It is most often done on an outpatient basis under general anesthesia. Post-operative pain is generally minimal and prevented with an abundance of icy or cold foods. Spicy foods, such as jalapeños or curries, should be avoided. The procedure can sometimes be combined with a tonsillectomy if needed. Recovery time can range from several hours to two or three days (though as age increases so does recovery time).

Adenoidectomy is not often performed on children under 1 year old as adenoids help the body's immune system but their value decreases rapidly once children reach this age. Adenoids become vestigial organs in adults.

History

The early version of adenoidectomy involved using a ring forceps through the nasal cavity to remove adenoid tissue by William Meyer in 1867. By the early 1930s the operation became nearly universal in children of school age.

Adenoidectomies began to be routinely performed together with tonsillectomies in the early 1900s. Initially, the procedures were performed by otolaryngologists, general surgeons, family practitioners and general physicians but over the past 30 years it became common that tonsillectomies and adenoidectomies are performed almost exclusively by otolaryngologists.

Adenoidectomies were indicated in cases of anorexia nervosa, mental retardation, enuresis or for one's well-being and to promote good health. At this time, the indications may seem odd, they may be explained as children may fail to thrive if they have chronically sore throats or severe obstructive sleep apnea (OSA). Obstructive sleep apnea is a medical condition that has been related to enuresis. Also, children who hear poorly because of chronic otitis media may have speech delay and be mistaken for mentally retarded. Adenoidectomies help resolve ear fluid problems, speech delays, and perceptions of low intelligence. Enuresis has actually been studied and listed as an indication for tonsillectomy and adenoidectomy (T&A) because large tonsils and adenoids block normal breathing through the nose and mouth, which interrupts sleep architecture and decreases normal brain and brainstem control of urinary function.

The incidence of the procedure declined starting with the 1930s as the use of the procedure became controversial. Treating tonsillitis and adenoiditis became easier and no longer required surgery as antimicrobial agents were developed and it is obvious that the upper respiratory infections were going through a decline among the older school-aged children. Also, at that time several studies showed that adenoidectomies and tonsillectomies were ineffective as well as the existence of an increased risk of developing poliomyelitis. Once the opinion pendulum began to swing towards avoidance of surgery, good prospective clinical trials, which have been performed over the last 2 decades, were required to prove to the medical and lay community that good indications for tonsillectomy and adenoidectomy (T&A), tonsillectomy alone, and adenoidectomy alone, exist.

Frequency

Obtaining recent information about how often the procedure is performed is quite difficult mainly because this type of surgery is nowadays performed in outpatient basis, and in these cases data is not well recorded. However, many doctors believe that adenoidectomy and tonsillectomy are performed too often.

The incidence of the procedure can clearly be observed for some decades ago, when the procedure was performed on an inpatient basis. According to the data recorded in 1971, more than 1 million Americans underwent tonsillectomies or adenoidectomies procedures, combined or alone, from which 50,000 consisted of adenoidectomy alone.

The existent data shows that by the late 1980s, the number or combined or single surgical procedures have decreased by 4 times, to 250,000 tonsillectomies and adenoidectomies. In 1987, the number of adenoidectomies alone decreased by more than three times, to 15,000.

However, this was the period when adenoidectomy started being performed on an outpatient basis and therefore it is now difficult to estimate an accurate number of procedures that are performed nowadays. In current practice, almost all adenoidectomies alone are performed in outpatient settings unless other issues or medical problems require hospital admission or an overnight stay..

Currently, adenoidectomy is indicated in children with obstructive adenoids, recurrent or chronic sinusitis, recurrent or chronic adenoiditis or to prevent recurrent or chronic otitis media. The surgery is only contraindicated in cases when general anesthesia carries too many risks for a patient's health.

Etiology

Adenoids develop from a subepithelial infiltration of lymphocytes after the embryo gets into the 16th week. Adenoids are a part of the Waldeyer ring of lymphoid tissue together with the palatine tonsils and the lingual tonsils. On histology, the tonsils contain 10–30 crypts lined by antigen processing stratified squamous epithelium and they have germinal centers as in other lymph tissue.

After birth, adenoids begin to enlarge and they keep growing until the individuals are aged 5 to 7 years. It is common that in infants of 18 to 24 months the adenoids are symptomatic, meaning that snoring, nasal airway obstruction and obstructed breathing usually occur during sleep. Over time, adenoids become gradually asymptomatic as when children reach school age, adenoids are expected to begin to shrink and when they reach teenage years, the adenoids should become small enough to not cause any symptoms.

The establishment of the upper respiratory tract is initiated at birth. Species of bacteria such as lactobacilli, anaerobic streptococci, actinomycosis, Fusobacterium species, and Nocardia are normally present in children of 6 months old. Normal flora found in the adenoid consists of alpha-hemolytic streptococci and enterococci, Corynebacterium species, coagulase-negative staphylococci, Neisseria species, Haemophilus species, Micrococcus species, and Stomatococcus species.

Infection of the adenoids can lead to the development of ear, nose and sinus illnesses.

Pathophysiology

Adenoids can harbor chronic infections and this way they may contribute to recurrent sinusitis and recurrent or persistent ear disease. The type and amount of pathogenic bacteria seem to vary based on the disease present and the age of the child. Also, enlarged adenoids and tonsils may lead to the obstruction of the breathing patterns in children, causing apnea during sleep.

The most common types of bacteria that affect the adenoids and cause infections in both children and adults are Haemophilus influenzae, group A beta-hemolytic Streptococcus, Staphylococcus aureus, Moraxella catarrhalis, and Streptococcus pneumoniea. Heamophilus influenza, Moraxella catarrhalis and Streptococcus pneumonia are the three most resistant pathogens of otitis and rhinosinisitis in children suffering from these diseases.

Adenoidectomies, no matter the size of the adenoids, improve the symptoms of rhinosinusitis and decrease the risks of recurrent or persistent middle ear effusions or infections in children older than 3 years. Also, in pre-menopausal adult women, an adenoidectomy can lead to a short term increase in breast mass.^{[citation needed]}

In 1999, a presentation at the American Academy of Pediatrics confirmed this concern by finding that adenoidectomy usually controlled symptoms and infections in children with large adenoids; however, if the adenoid was small and CT scan evidence of chronic sinusitis was present, not as many children improved, leading the authors to believe these children would benefit from initial procedures of adenoidectomy and endoscopic sinus surgery.

References

• Darrow D, Siemens C (2002). "Indications for tonsillectomy and adenoidectomy". Laryngoscope 112 (8 Pt 2 Suppl 100): 6–10. doi:10.1002/lary.5541121404. PMID 12172229. 
• Derkay C, Darrow D, LeFebvre S (1995). "Pediatric tonsillectomy and adenoidectomy procedures". AORN J 62 (6): 885–904. doi:10.1016/S0001-2092(06)63556-4. PMID 9128745. 

External links

• Adenoidectomy Information
• eMedicine – Adenoidectomy