Methods
bleeding, sleep disorder, Pain, choanal atresia, adenoid, Postoperative bleeding, ’ postoperative pain, palate, retrognathia or macrognathia, sleep disordered breathing, nasal obstruction, adenoid hypertrophy, maxillofacial anomalies, cleft lip, adenoid mass
OTITIS MEDIA WITH EFFUSION, HYPERTROPHIED, BLEEDING, POSTOPERATIVE BLEEDING, ALLERGIC RHINITIS, OTITIS MEDIA, PAD, BLIND, SLEEP DISORDERED BREATHING, COAGULATION DISORDER, ADENOID HYPERTROPHY, COMPLICATIONS
This prospective randomized study was conducted on 90 patients with symptomatic adenoid hypertrophy such confirmed by nasopharyngeal X-ray and endoscopic grading preoperatively. Patients were selected from general population including patients reporting to Otorhinolaryngology outpatient clinics of Al-Azhar University hospitals during the period from January 2022 to January 2023. It is approved by the ethical committee of the University with ethical No. (412/ENT/2022).Inclusion criteria were only children aged from 3 to 12 years old with symptomatic adenoid hypertrophy, children with sleep disordered breathing due to adenoid hypertrophy, tonsillectomy candidates that were assessed for the presence of asymptomatic adenoid hypertrophy, and these patients had no history of attack of otitis media in the last 6 months.Exclusion criteria were patients having significant nasal obstruction due to other causes such as: (allergic rhinitis, septal deviation, hypertrophied inferior turbinates or sinonasal polyps), patients with congenital nasal or maxillofacial anomalies such as: cleft lip and palate, choanal atresia, retrognathia or macrognathia, or patients with coagulation disorder, plus patients with past history of myringotomy, grommet tube, recurrent otitis media with effusion.Patients were subjected to the following: (1) detailed history taking and clinical examination. (2) radiological evaluation of the adenoid by X-ray lateral view on the nasopharynx. (3) endoscopic grading of adenoid size using flexible endoscopy (4) tympanometry for all patients.Preoperatively, before general anesthesia fiberoptic adenoid endoscopy was done with a 2.7 mm fiberoptic endoscope (Karl Storz, Germany). The aim of this examination is to detect the adenoid size grading as four grades as following: when only upper part of nasopharynx (free choanae) occupied by adenoid mass was classified as grade 1 (≤ 25%). Adenoid tissue occupied equal or less than 50% of nasopharynx with sufficient choanal opening and sufficient tubal visualization was classified as grade 2. If adenoid tissue occupies about 75% of the nasopharynx with partial involvement of the tube ostium and considerable obstruction of choanal openings was classified as grade 3. If adenoid tissue reaches the lower choanal border without allowing visualization of the tube ostium (> 75%) was classified as grade 4 [All patients underwent polysomnography before adenoidectomy to assess the presence of sleep disorder; then under general anesthesia all patients were operated either as a single procedure or along with other procedures like tonsillectomy. The patients were tabulated on computer and depending on double blind they were divided randomly into three groups: Group I of 30 patients had conventional adenoidectomy, Group II of 30 patients had endoscopic microdebrider-assisted adenoidectomy, and Group III of 30 patients had coblation adenoidectomy.Intraoperative endoscopic nasal examination after adenoidectomy was done to evaluate the presence of adenoid remanent in both groups and to control bleeding. Patients were recorded for operative time, operative and post-operative complications. Pediatric flexible nasopharyngoscopy was done for all patients 6 months postoperatively for re-assessment of the nose and nasopharynx. Informed written consent was obtained from all patients.Conventional adenoidectomy: patients were subjected to general anesthesia via an orotracheal tube. Then the child was placed in supine in the Rose position and Boyle Davis mouth gag was inserted as in tonsillectomy. Then St. Clair Thompson adenoid curette was used to perform a conventional adenoidectomy. A 70° endoscope was used for assessment of the presence of posterior pharyngeal wall injury or remnant of adenoid tissue. Ribbon gauze was placed in the nasopharynx for attaining hemostasis and was removed after 5 min.Endoscopic microdebrider-assisted adenoidectomy: patients were subjected to General Anesthesia via an orotracheal tube. Then the child was placed in supine in the Rose position and Boyle Davis mouth gag was inserted as in tonsillectomy. With the use of endoscope, the Microdebrider unit was set at 3000 rpm oscillating mode to remove the adenoid tissue from the choanal and tubaric regions transorally. Once all the adenoid tissue was removed, ribbon gauze was placed in the nasopharynx for attaining hemostasis and was removed after 5 min. Microdebrider with special adenoid blade, which is longer, has a window on convex side for use transorally to adapt to the roof of nasopharynx. A 70° sinoscope and angled microdebrider was passed transorally. The adenoidectomy was started high in the nasopharynx from upper limit of adenoid tissue, which often cannot be reached by conventional curette. Resection was continued from one side to another side fashion on an even level until the inferior edge of adenoid pad will be reached. The cutting and aspirating action of the shaver and simultaneous irrigation removes both adenoid tissue and the blood, thus providing a clear view. Postoperative care was given and patient was discharged the same day.Postoperative endoscopic assessment of any adenoid remnant after 6 months was done. Postoperative bleeding was evaluated postoperatively. The patients’ postoperative pain assessment were compared using VAS from 0 to 5 before operation, after 2 weeks, and 3 months after adenoidectomy as shown in Fig. Pain scale according to facial expression [Data were fed to the computer and analyzed using IBM SPSS software package version 20.0