Adenotonsillectomy - Pediatric - technical
Synonyms are Intracapsular tonsillectomy; Tonsillotomy;
The complete or partial removal of pharyngeal tonsillar lymphoid and adenoid tissue.
Adenotonsillectomy continues to be one of the most commonly performed surgical procedures in the Western world. Surgery for adenotonsillar disease is safe and effective as demonstrated in terms of health care costs and quality-of-life measures.
The indications for tonsillectomy have shifted over the past 40 years. In the early 1970s, close to 90% of tonsillectomy procedures were performed in response to infections. Today, most procedures are performed to treat sleep-disordered breathing (SDB), which is defined as a continuum from primary snoring to obstructive sleep apnea (OSA). This trend reflects not only improved control with antibiotics of the complications of group A streptococcal pharyngitis, but also increased rates of childhood obesity, a concomitant and perhaps related increase in the diagnosis of SDB, and a greater awareness of the impact of SDB on children’s educational progress and cognitive development.
A revitalization of “older” techniques (such as tonsillectomy), the development of new technologies (such as powered microdebridement and Coblation®), and the drive to measure, report, and improve surgical outcomes have resulted in a wider range of operative approaches to adenotonsillectomy than that which was available in the past (Shah 2008). A broad variation in the types of techniques is practiced amongst surgeons.
A more recent survey found regional variations among surgeons’ use of tonsillectomy devices (Fig. 1) (Shah and Terk 2009). A survey of pediatric ORLs found differences in the instruments and technique by indication for surgery with fewer surgeons using intracapsular microdebrider techniques for infection (Walner et al. 2007). At the authors’ institution, nearly all tonsillectomies are performed using intracapsular techniques whether by microdebrider or by Coblation®.
The American Academy of Otolaryngology – Head Neck Surgery (AAO-HNS) does not advocate one technique over another (AAO-HNS 2007). A breadth of surgical experience across the various options enables the surgeon to fit the best procedure to the individual patient and circumstance. With the exception of tonsillectomy for tumors, in which case cold or monopolar complete tonsillectomy is recommended in order to optimize histopathological analysis and assessment of the tonsillar capsule, the authors of this artice generally defer to the surgeon’s judgment in recommending a specific procedure for their patient, and they trust that appropriate referral will be made to another provider if a surgeon is not confident in their ability to perform the required procedure.
This article offers a brief review of the pertinent anatomy, explains several of the more common technologies used today for adenotonsillectomy, and details the authors’ techniques.
The exophytic lymphoid tissue encircling the posterior oropharynx is collectively known as Waldeyer’s ring, and it is classically separated into three distinct structures: the palatine tonsils, the adenoid (“the nasopharyngeal tonsil”), and the lingual tonsil. Lymphoid tissue around the Eustachian tube tori (Gerlach’s tonsils) may be considered a fourth, distinct entity. The palatine tonsils are bounded anteriorly and posteriorly by the palatoglossus (anterior pillar) and palatopharyngeus (posterior pillar), respectively. A fibrous capsule envelops the tonsil laterally and separates the lymphoid tissue from the superior constrictor muscle. The loose areolar tissue that fills this potential space may become fibrotic and friable in chronic or recurrent tonsillitis making dissection difficult. The tonsils are bound by the soft palate superiorly and by the musculature of the tongue and lingual tonsil tissue inferiorly. The arterial blood supply usually derives superiorly from branches of the internal maxillary artery. The inferior vascular pedicle is frequently the most prominent and derives from branches of the facial artery and external carotid. Venous outflow occurs via the pericapsular venous plexus, which drains to the lingual, pharyngeal, and internal jugular veins. In adults, the carotid space is approximately 2.5 cm posterolateral to the tonsillar fossa.
The adenoid pad rests on the posterior nasopharyngeal wall superior to the soft palate. Superiorly, the adenoid pad begins just posterior to the nasal septum and choanae – very large adenoid tissue can grow into the nasal vault here and is referred to colloquially as “choanal adenoid.” Laterally, adenoid tissue may extend to the torus tubarius immediately medial to the fossa of Rosenmuller. The adenoid usually ends inferiorly above Passavant’s ridge, a submucosal prominence of the superior pharyngeal constrictor. Rarely, adenoid tissue is so large, or the nasopharynx is so steeply angled and shallow, that the adenoid may be seen inferior to the soft palate transorally. The ascending pharyngeal and descending palatine arteries, both ultimately branches of the external carotid, supply blood to the adenoid tissue. Venous drainage occurs via the pharyngeal plexus or, less commonly, the pterygoid plexus.
Pre- and Perioperative Considerations
Preoperative blood work (i.e., complete blood count and coagulation studies) is recommended for those patients with a family or personal medical history suggestive of a bleeding diathesis or when genetic information about the biological family is unavailable. Hematologic evaluation and recommendations are helpful for perioperative management when coagulopathy or platelet dysfunction is suspected or present (e.g., use desmopressin [1-desamino-8-D-arginine vasopressin (DDAVP)] for patients with von Willebrand disease).
When dealing with pediatric patients, it is important to know the preoperative weight; it will help guide medication dosages, discharge recommendations, and considerations for blood loss. Total blood volume can be estimated at 75 ml per 1 kg of body weight. This value is slightly higher in newborns, who have an estimated blood volume of 80–90 ml/kg. Maximum allowable blood loss can be approximated with the following equation: (estimated blood volume) ([hematocrit 25]/ [hematocrit]). Blood loss over 100 ml sometimes occurs and may pose a concern especially in younger children with low total blood volumes.
Administration of a single dose of 0.5–1 mg/kg of dexamethasone up to a maximum one-time dose of 10 mg at the start of the procedure has been consistently shown to decrease postoperative pain and nausea with negligible morbidity or cost. While perioperative antibiotic prophylaxis has been advocated to hasten the return to activity and diet, there is not sufficient evidence to support routine use of antibiotics, due to concerns over bacterial resistance, risk of allergic reactions, and other side effects (Baugh et al. 2011).
Adenotonsillectomy is practiced primarily as an elective ambulatory procedure. There are, however, exceptions to this norm that must be recognized in order to ensure safe perioperative planning. A systematic review by Brigger et al. of the literature on outpatient tonsillectomy applied subgroup analysis to pooled data and demonstrated an increased risk of complications and unplanned admissions in children younger than 3 years (Brigger and Brietzke 2006). Obese children constitute another high-risk subgroup, as they have been shown to develop respiratory complications at a higher rate than controlled counterparts when undergoing tonsillectomy for SDB. Planning for postoperative admission with interdisciplinary-care coordination is recommended for certain high-risk subgroups: children younger than 3; children with a BMI over 95%, or with severe OSA; children with cardiac, pulmonary, hematologic, and/or metabolic disorders; and children with conditions requiring special fluid restriction or metabolic control (such as diabetics). Discharge should occur after concurrence between the patient’s family, surgeon, anesthesiologist, and recovery-room staff.
The microdebrider is an oscillating tool that consists of a variably sized, serrated blade within a hollow cylinder. Suction within the cylinder pulls tissue into a partial opening at the tip and permits gentle tissue resection. At lower speeds, it allows for hemostasis as very small vessels are compressed and blood is suctioned. Saline within the unit prevents clogging. The typical speed setting for adenotonsillectomy varies from 800 to 1,800 revolutions per minute (RPM). The device can be used for both soft (lymphoid) as well as hard (bony [e.g., clival], cartilaginous, or septal) tissue; thus, precise application is critical.
Coblation® is the application of a bipolar radiofrequency current that generates a localized plasma field, which is used to dissect tissue. A low power electrocautery current that provides vessel coagulation is produced simultaneously. Larger vessels may be addressed separately with the cautery-only setting. A constant flow of saline irrigation is passed through the tip of the wand. The senior author of this article advocates regular, intraoperative tip cleaning by abrasion against a thick, cloth towel while hitting the “ablate” foot pedal; suction of mildly soapy saline will prevent wand clogging. More specific instructions are found in other work (Shah 2008). This technique provides a clean, hemostatic plane-of-dissection with minimal thermal damage. Because the ablation setting easily dissects through tissue, it is important to ensure only the coagulation setting is applied to cauterize vessels. This technology can be used for either traditional or intracapsular techniques.
The theoretical benefit of Coblation is that this plasma field occurs at relatively low temperatures (between 60C and 70C) and thus results in less thermal injury than monopolar cautery (Shah and Terk 2009). Improved recovery as measured by less pain medication use, earlier return to diet, and equivalent complications to other technologies have been shown in the literature (Stoker et al. 2004; Shah and Dunham 2007).
In PlasmaCision®, the jPK™ device generates a localized plasma energy field. PlasmaCision® differs from Coblation in that local tissue electrolytes replace the need for exogenous saline. The jPK™ device is used similar to a Coblation® wand or monopolar electrocautery wand to perform a traditional tonsillectomy (Shah and Terk 2009). Both traditional and intracapsular techniques can be performed with PlasmaCision®.
Radiofrequency ablation has been reportedly used to perform partial tonsillectomy or tissue reduction primarily for sleep-disordered breathing in children. Advocates report that it produces decreased postoperative pain with minimal morbidity (Hultcrantz and Ericsson 2004).
As in the Coblation® technique, the harmonic scalpel is thought to deliver lower amounts of thermal damage as tissue resection is performed using high-speed vibratory tissue dissection, thus causing less postoperative pain and morbidity. Increased reports of intraoperative hemorrhage are balanced against reported lower rates of postoperative hemorrhage and improved healing attributed to decreased thermal spread (Kamal et al. 2006).
Adenotonsillectomy in the United States is typically performed with the patient under general anesthesia. The patient is placed in the “Rose position” – supine with the neck extended and a shoulder-roll in place. Head and spine extension and rotation should be undertaken with caution in patients with cervical spine concerns (as those with trisomy 21). Ventilation may be performed using an endotracheal tube or laryngeal mask airway. Dentition should be inspected for looseness or chipping, and any concerns should be documented before and after the procedure.
Exposure is achieved using a McIvor or Crowe- Davis-style mouth gag, and suspension is usually achieved by hooking the device to a Mayo stand across and above the patient’s chest. An “open-sided” mouth gag (Fig. 2) optimizes exposure by permitting better angulation and visualization, which are particularly useful during adenoidectomy. Gags that open both to the left and to the right side are available.
Figure 2: Open-sided mouth gag (Davis mouth gag; Medtronic-ENT, Jacksonville, FL, USA)
Bupivicaine (0.25%) with 1:200,000 epinephrine is injected through the anterior tonsillar pillar into the peritonsillar space. This allows for added hemostasis, improved pain control, and “hydrodissection.” Hydrodissection facilitates surgery whether extracapsular or intracapsular. With experience, one can inject into the appropriate tissue plane particularly if surgical loupes are worn. The fluid-filled peritonsillar space is particularly useful with Coblation®. Injection also facilitates surgery by medializing the tonsillar tissue, which is very helpful for endophytic tonsils.
Further exposure is achieved after infiltration with bilateral, transnasal, non-latex catheters to retract the soft-palate cephalad. This provides tissue tension for tonsillectomy, enhanced visualization, and it reduces the risk of palatal injury during adenoidectomy.
Adenoidectomy may be performed using an adenoid curette, microdebrider, or with Coblation® or electrocautery techniques. Following curette or microdebridement, electrocautery is frequently used to achieve superior hemostasis. Prior to proceeding with adenoidectomy, the soft palate should be inspected and palpated for a submucus cleft palate, which is suggested by a bifid uvula with sometimes visible and generally palpable midline separation of the softpalate musculature and by palpation of a notch in the hard palate. Maintaining a central or inferior ridge of adenoid tissue reduces the likelihood of postoperative velopharyngeal insufficiency (Velopharyngeal Dysfunction, Diagnosis and Management) particularly in patients with a suspected submucus cleft palate.
Prolonged soft-palate retraction may lead to edema that can compromise postoperative breathing and swallowing. Intermittent relaxation of the catheters is recommended when procedure time is in excess of 30 min. A laryngeal mirror or rod-lens telescope may be used to visualize the adenoid pad. The surgeon must always be cognizant of the conductive capacity of the metal mirror-shaft and should keep a gloved finger between the shaft and any oral mucosa while using electrocautery or Coblation® (Shah and Terk 2009). The Eustachian tube tori laterally, the posterior aspects of the inferior nasal turbinates, and the nasal septum should be protected. An approximately 2–3-mm-high ridge of adenoid tissue left inferiorly can help prevent VPI. Approximately 1–2 mm of adenoid tissue may be left at the “floor” of the surgical field (really the roof of the nasopharynx) against the posterior pharyngeal wall to prevent excessively deep dissection into the retropharyngeal or prevertebral spaces. Posterolaterally (the “high deep corners” of the nasopharynx), the depth of resection should also be limited to prevent profuse bleeding.
The adenoid curette is placed in the nasopharynx to the level of the choana and, in a forward sweeping motion, the curette resects adenoid tissue when the blade is sharp by gentle, bimanual, forward to-and-fro motion. For the right-handed surgeon, the left thumb is placed in the divot on the shaft of the curette to gently push posteriorly. The right thumb and palm provide anterior pressure with direction and oscillation from above (Fig. 3).
Figure 3: Adenoid curette hand position
The curette should achieve a gentle “upward climb” assisted by the left thumb upon approaching the inferior adenoid pad to permit an inferior hedgerow of adenoid tissue as recommended above. Multiple passes with progressively narrower curettes may be necessary to ensure adequate tissue reduction. Remaining adenoid tissue may be removed with a St. Clair-Thompson forceps, a sponge-covered gloved finger, or electrocautery.
Microdebridement of the adenoid pad proceeds in a cephalad-to-caudal direction. A gently angled (30–40) “adenoid blade” is used, with or without coagulation, at variably oscillating resection between 800 and 1,800 RPM.
In most cases, when the Evac® Xtra wand is used, tissue reduction for adenoidectomy is achieved at settings of 9 for “ablate” and 5 for “coag.” The authors prefer this specific iteration of the Coblation® devices due to its large central suction channel, which prevents clogging and facilitates hemostasis.
Ablation should proceed in a saline pool with the tip of the instrument hovering slightly above the tissue. Moving slowly during adenoid tissue ablation with frequent suctioning of the “lightly soaped” saline solution avoids clogging of the wand. Cleaning the grill of the wand against a moistened towel by pressing “ablate” and gently brushing the grill against the towel ensures pristine electrodes for effective energy delivery. Gentle and slow application of the Coblation® wand on the “ablate” setting is usually effective to reduce adenoid tissue hemostatically without the need for electrocautery. Suction electrocautery tends to be needed rarely, but more frequently for hemostasis for the infected adolescent adenoid (Fig. 4).
A suction “Bovie,” set initially on a “fulgurate” and then switched to a “blend” current distribution between 15 and 35 W power, is manually contoured to an angle between 20 and 40 (this angle mirrors that of the adenoid blade used with microdebridement). Wand clogging is reduced by frequent suctioning of saline; saline suctioning in addition to frequent visual confirmation of insulation integrity along the device shaft helps to reduce shaft heat and the attendant risk of skin or mucosal injury. It is important to make sure that the foot pedal is released when entering or exiting the pharynx for microdebrider, cautery, and Coblation®.
Suction “Bovie,” Coblation®, and tonsil sponges are usually effective for hemostasis. For microdebriders with a cautery capability, some surgeons are able to achieve effective hemostasis without the need for additional electrocautery. Brisk nasopharyngeal bleeding is controlled by a tonsil sponge applied to one side of the nasopharynx while a transnasal suction catheter is placed in the “open” side to evacuate blood and smoke. Prevent fire during cauterization by instilling saline intermittently to reduce heat and evacuate clot and by maintaining suction Bovie-tip distance away from the flammable plastic catheter tip.
Traditional tonsillectomy may be performed with any number of instruments (e.g., cold steel, monopolar or bipolar cautery, plasma knife, or Coblation® devices). Although subtle differences exist between the use of each device whether intra- or extracapsular, the underlying principles are optimizing exposure and tissue tension and then finding and staying in the proper plane-of-dissection. The tonsil is grasped with an Allis tenaculum and retracted medially. Repeated medial and lateral displacement of the tonsil allows for appreciation of the depth of the tonsil tissue with respect to the anterior and posterior pillars. As highlighted in the Adenoidectomy section, any metal instrument used for retraction or visualization purposes should be buffered from the oral mucosa by a gloved finger to prevent thermal burns while performing electrocautery, Coblation®, or PlasmaCision®.
A curvilinear mucosal incision is made at either the lateral margin on the tonsil or at the superolateral aspect of the anterior pillar. The incision can be made with a sickle knife in the case of cold-steel tonsillectomy, monopolar cautery, or the ablate function on the Coblation® wand. Following inferomedial displacement of the tonsil with the Allis clamp, dissection begins. The fibrous tonsillar capsule is recognized when loose areolar tissue is encountered. In patients suffering only from sleep apnea, the potential space between the tonsillar capsule and constrictor musculature is an easily separable plane. However, if the patient has had recurrent tonsillar infections, this plane may become hypervascular and scarified; in this case, recognizing the plane is more challenging.
Once the fibrous capsule is identified, dissection along this plane typically continues in a superior-toinferior manner. Loss of the plane-of-dissection by violating the tonsil tissue or the constrictor musculature should be immediately recognized, either by a change in the tissue’s smell (“burnt flesh” if the tonsil is entered) or by a visualized loss of the sheen of the tonsillar capsule, and corrected (Of note: the authors routinely wear surgical magnifying loupes for tonsillectomy, which aid in subtle visual distinction of intra- versus extracapsular planes.). A number of instruments may be used to perform this dissection including a Hurd dissector, a Fisher knife, or a Freer elevator. The Fisher knife has a serrated, hockey-stickshaped end. It is manipulated by placing the serrated edge into the plane-of-dissection and slowly pushing the instrument forward to elevate the tonsil from the underlying musculature while simultaneously providing continuous medial traction with the tenaculum. Monopolar electrocautery and Coblation® techniques proceed in a similar manner: the surgeon uses medial traction and rotation (Fig. 5) while slowly cauterizing or coblating through the potential space. With the use of either device, areas of hypervascularity may be “precoagulated” to provide improved hemostasis prior to dissection.
Figure 5: Medial rotation for tonsillectomy
Once the superior pole is freed from the tonsillar fossa, it is often necessary to reposition the Allis clamp to provide constant surgical tension; however, multiple passes at grabbing tonsillar tissue often leads to fragmentation and bleeding thus compromising further dissection. Dissection is continued in a systematic manner inferiorly toward the inferior pole, which is the site of significant blood supply. Frequently, the tonsil tissue lacks an obvious inferior extent, and instead blends into the lingual tonsil tissues. As the inferior pole is approached, a decision must be made to dissect through some of the lymphoid tissue. To prevent excessive bleeding, avoid extensive dissection inferiorly. Rather, Coblation® on “ablate” or electrocautery to truncate the inferior pole is recommended. The surgeon should use a gentle, medial sweep following the curvature of the superior tonsillar tissue.
Intracapsular tonsillectomy (ICT), also referred to as partial tonsillectomy or tonsillotomy, involves the exteriorization of tonsillar crypts by removing most of the lymphoid tissue of the tonsil and leaving a thin rim of tissue against the tonsillar capsule. Preserving a thin rim of tissue facilitates healing, reduces dehydration and returns to the OR for hemorrhage, and expedites recovery (Schmidt et al. 2007).
Multiple techniques for ICT have been described: carbon dioxide laser, bipolar scissors, Coblation®, electrocautery, and powered microdebridement. The most common approaches to ICT today aremicrodebridement and Coblation®.
Straight and angled blades may be used for ICT at a variable rate of oscillation between 800 and 1,800 RPM. Instead of grasping the tonsil with a tenaculum, the tonsillar tissue is presented using the blunt end of a Hurd retractor applied laterally against, and “toeing” into, the anterior tonsillar pillar while lifting the Hurd up toward the surgeon; this everts the tonsil. Gradual, lateral tissue resection proceeds from the center of the tonsil to the upper pole and permits for optimal tissue removal superiorly. The surgical limit of dissection is identified by noting the stringy appearance of pericapsular fibers, which are best appreciated when using magnifying surgical loupes.
ICT with Coblation®:
Two techniques are effective for partial Coblation® tonsillectomy: the “lop-off” technique for large, exophytic tonsils, and the “reduction” technique for endophytic tonsils.
The “lop-off” technique: With large exophytic tonsils, the Coblation® approach is similar to that taken during total tonsillectomy. The body of the tonsil is grasped with a tenaculum that is then used to medialize the tonsil. Once the lateral extent of the tonsil is appreciated via palpation with the instrument, a curvilinear mucosal incision is made in the superolateral anterior pillar. This incision should be slightly medial to the desired location of a mucosal incision for total tonsillectomy so that the tonsillar capsule is left down within the fossa. By employing a slow, deliberate brushing technique with the “ablate” mode, the surgeon will expose a shiny, white plane of white capsule, again, best seen using surgical loupes. This tissue is the tonsillar capsule and should be preserved within the fossa as the lymphoid tissue is excised. Firm medial tonsillar retraction is helpful here: the surgeon should “feel the burn” (in athletic muscular terms) in their thenar eminence as they learn this technique. This assures firm retraction, which protects the capsule and the pillars. Spot hemostasis can be achieved during dissection by switching to the “coag” mode to cauterize any individual vessels encountered. Once the tonsil has been removed, hemostasis can be completed with the “coag” setting (Fig. 6).
Figure 6: Coblation ICT using the lop-off technique
The “reduction” technique: Small, endophytic tonsils can be approached with a slightly different technique. With a tenaculum, the tissue is grasped and retracted medially. The lateral extent of more endophytic tonsils can often be difficult to appreciate. In this circumstance, the “ablate” setting can be used to shave the tonsil down along the sagittal plane of the pillars. Care must be taken to keep the tip of the wand directed medially at all times. Inevitably, stumps of lymphoid tissue, likened to small growths of shrubbery, are left behind within the tonsillar fossa. This remaining tissue can be reduced by switching to the “coag” setting and directing the wand laterally. This same technique can be applied in the setting of chronic or recurrent tonsillitis. In these circumstances, the cryptic and friable tonsillar tissue can be difficult to grasp or retract with the tenaculum and may be ablated in a piecemeal manner. Once the tonsil has been resected to the sagittal plane of the pillars, the remaining tissue can be reduced with the “coag” setting.
Regardless of technique, hemostasis must be achieved following removal of lymphoid tissue. A tonsil sponge can be used to apply pressure to the tonsillar fossa followed by electrocautery using monopolar (Bovie) or bipolar (Coblation®) techniques or 3–0 chromic sutures with atraumatic needles. Severe bleeding refractory to cautery or sutures may require tissue sealants (fibrin) or hemostatic agents (thrombin). Pillar placation may also be applied in such difficult cases with the additional benefit of opening the pharyngeal airway further as adjunctive management for obstructive indications. The authors recommend relaxation of the transnasal catheters and removal from suspension with closure of the mouth gag for a defined time period (30 s by the clock) to permit vessels that may have been “pulled” closed during retraction to declare themselves and permit hemostasis upon re-exposure. In addition, relaxation permits edema of the soft palate, lips, and tongue and allows the uvula to regress.
Completion of Surgery
The oral cavity is irrigated with warm saline solution after tissue resection and initial hemostasis. The stomach and oral cavity are subsequently suctioned clear. Hemostasis is confirmed. Most importantly, electrocautery and surgical set-up should not be removed from the operating suite until the patient is extubated and taken to the post-anesthesia recovery area. Tonsil tissue should be sent for pathology only if significant differences in size between the tonsils are noted, or if there is a concern over abnormal tonsillar surface appearance (such as friability or a fish-flesh appearance). A suction sock can be used to capture specimen when neoplasia is suspected or microbiology is required for microdebrided tissue. Complete tonsillectomy is recommended when neoplasia is suspected, as is curette adenoidectomy, to facilitate histopathological evaluation.
Special Population Considerations
Trisomy 21 (Down Syndrome)
Children with Down syndrome have a high incidence of obstructive sleep apnea and, as a result, frequently undergo adenotonsillectomy. In addition to unfavorable anatomy that makes airway management difficult, a specific concern to the otolaryngologist is the increased incidence of atlantoaxial instability in this population. Atlantoaxial subluxation is the displacement of the first cervical vertebrae over the second cervical vertebrae and is known eponymously as Grisel’s syndrome when this occurs due to adenotonsillectomy. Untreated atlantoaxial subluxation can lead to severe neurologic consequences.
The craniofacial features of Down syndrome (i.e., midface hypoplasia, micronagthia, narrow nasopharynx, macroglossia, and short neck) exacerbate obstructive symptoms in this population. It is recommended that polysomnography should be performed in all trisomy 21 patients undergoing adenotonsillectomy in order to ensure adequate perioperative preparation and plans for post-procedure intensive care. Associated cardiac defects predispose this population to cor pulmonale and contribute to the recommendation for elective admission postoperatively. The multifactorial nature of UAO in trisomy 21 children may require more than just adenotonsillectomy.
Velocardiofacial (VCF) syndrome, the phenotypicmanifestation of the 22q11 chromosomal deletion, is among the more common identifiable malformation syndromes associated with clefts of the secondary palate. The palatal defects in these patients are most commonly occult submucosal clefts. Thus, a normal oropharyngeal exam in the office does not preclude the possibility that a VCF patient has an underlying palatal defect that could predispose her to post-adenoidectomy VPI.
Patients with VCF may have medial displacement of the internal carotid arteries into the nasopharynx. Therefore, when adenoidectomy is considered, imaging (CT and/or MRI) and flexible nasopharyngolaryngoscopy to assess for pulsations of the lateral nasopharyngeal walls and degree of airway impingement by the adenoid and tonsillar tissue are recommended.
If the decision is made to proceed with adenoidectomy, the soft palate should be palpated at the time of surgery. Should an occult submucus cleft be detected at that time, a ridge of adenoid tissue should be left behind centrally or inferiorly as described previously. An underlying syndromic genotype should be considered even in the face of an otherwise normalappearing phenotype, when VPI persists more than 3 months after adenoidectomy.
The use of electrocautery during the procedure places the patient at risk for mucosal burns and airway fire. These risks are best mitigated by avoiding arcing, buffering the interface of mucosal surfaces and metallic instruments with a gloved finger, and reducing inspired oxygen concentration to 25–30%. Saline or water to douse flames should be kept close at hand – usually on the Mayo stand serving as the instrument tray and suspension apparatus. If airway fire is suspected, immediately and simultaneously turn off the oxygen, remove the burning object (usually the endotracheal tube), douse the fire with saline or water, protect the airway via mask ventilation, reintubation, or bronchoscopy, and alert all persons in and around the operating room of the airway fire. A damage assessment and airway control must then proceed, and, if all is well, then surgery may be completed.
Primary hemorrhage, defined as bleeding within the first 24 h, is typically blamed on inadequate intraoperative hemostasis. Secondary or delayed hemorrhage occurs after the first 24 h. Secondary hemorrhage usually occurs between postoperative days 5 and 10 when the eschar sloughs and vessels within the healing tonsillar fossae are exposed. Adenoid bleeding is rare and may occur as long as 2–3 weeks after surgery. Surgical control of bleeding is usually required when blood loss is severe. Observation in the hospital setting is recommended for children in whom bleeding concerns are significant and no active bleeding or clot are seen upon evaluation.
Postoperative pulmonary edema:
Respiratory distress or desaturation at the conclusion of the case or in the immediate postoperative period, particularly when accompanied by frothy, sometimes pink tracheal secretions, may indicate postobstructive pulmonary edema (POPE). Relief by adenotonsillectomy of long-standing obstruction causes vasodilatation of the pulmonary vascular bed, which in turn increases hydrostatic pressure and leads to transudation of fluid into alveoli. Postobstructive pulmonary edema can be confirmed with chest x-ray, and initial management includes positive-pressure ventilation with supplemental oxygen and, in some cases, chemical diuresis. Rarely, POPE requires intubation and mechanical ventilation with ICU management.
Velopharyngeal insuuficiency (VPI): Transient
VPI can occur rarely after adenotonsillectomy. Postoperative VPI is best avoided by leaving a small pad of adenoid tissue inferiorly measuring approximately 2 mm in height. If symptoms of VPI, such as hypernasal speech and regurgitation of food or drink, persist beyond 8 weeks, then a speech and swallowing evaluation should be initiated.
Prolonged VPI is rare and should prompt investigation into possible predisposing conditions as discussed in the previous section on VCF Syndrome.
If unresponsive to speech therapy, VPI may require surgical treatment.
Nasopharyngeal and oropharyngeal stenosis are even more rare than VPI, but can be seen weeks to months after adenotonsillectomy. Symptoms include nasal obstruction, mouth breathing, and recurrence of obstructive sleep apnea. The pathogenesis is scarring, which results from the apposition of rawor thermally injuredmucosal surfaces – between the cephalad soft palate and nasopharyngeal roofmost commonly.
Prevention of palatal injury is best achieved by strong palatal retraction with full visualization of all surfaces (particularly with the microdebrider, suction “Bovie,” and with Coblation®), as well as by avoidance of excessive cautery in the nasopharynx. For this reason, some surgeons never cauterize in the nasopharynx and instead achieve hemostasis by pressure alone. Diagnosis of stenosis is made with nasopharyngoscopy and the treatment is surgical.
Surgeons today have the ability to apply a wider variety of techniques and technologies to treat adenotonsillar diseases than ever before. Analyses of the results and economic costs across prospectively studied, large patient populations over varying ages, indications, and for time periods in the 3–5 years range will permit for more prudent application and teaching.
In the meantime, it behooves surgeons to be aware of the opportunities and limitations presented by these various options and to undertake responsible use of these technologies through appropriate training and mentoring.
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