Adenoid Removal - Surgical Technique, Indications, Risks and Cost
Adenoid Hypertrophy
How does an adenoid develop and grow?
Causes of Adenoid Hypertrophy
Adenoids tend to grow in the first 6 years of life. The most striking factors in adenoid growth are genetic predisposition and environmental factors. Causes of adenoid growth:
- Being in an environment containing allergens, particles and polluted air
- Exposure to cigarette smoke and polluted air
- Living in a crowded environment (such as a nursery environment)
- Genetic predisposition
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| X-ray graph - enlarged adenoid (hypertrophy) - air passage is look like very narrow |
In the above adenoid radiography (adenoid x-ray) and the photographs obtained from the following endoscopic intranasal examination, it is seen that the adenoid closes the airway behind the nose.
Symptoms of Adenoid Hypertrophy
Many different symptoms may occur in children depending on the enlargement of the nasal congestion and the associated nasal congestion:
- Stuffy nose
- Sleeping with mouth open
- Gum disease
- Decrease in concentration and lesson success in school
- Poor sleep quality
- Sleep apnea symptoms (more pronounced in children with large tonsils as well)
- Difficulty sleeping on your back and more comfortable sleeping on your side
- Incontinence (more common in children with sleep apnea)
- Bad breath
- Middle ear infections
- Sinusitis
Recurrent or non-healing middle ear effusion or middle ear infections
1. It is thought that the adenoid grows and the core tube, which is mainly responsible for middle ear aeration, closes the opening holes in the nasal cavity, therefore eustachian tube dysfunction occurs and the natural cleaning process of the middle ear cannot be performed. Already in the period when the adenoid is growing, the development of the eustachian tube is not complete and it cannot function properly. Adenoid enlargement causes additional adverse effects on eustachian tube functions.
2. It is thought that the adenoid , like a garbage can, collects the germs and all particles on which the air taken from the nose rotates and collects there, and the microbes that accumulate and reproduce here can go back to the middle ear through the eustachian tube, causing recurrent otitis media and ear effusions. There are studies showing that the microbes obtained from children with otitis media are almost the same as those obtained from the adenoid.
There are studies showing that nasal surgery significantly reduces the frequency of middle ear infections in children over the age of 3 due to the reasons I mentioned above. In patients with long-term adenoid enlargement and collapse in the eardrum, structural changes or chronic middle ear effusion, adenoid surgeries and ear tube surgeries are also performed together.
Recurrent episodes of sinusitis or chronic sinusitis
Many studies show that adenoids act as a reservoir of infection in patients with chronic sinusitis and recurrent episodes of sinusitis. In other words, pathogenic microbes reproducing in the adenoid spread to the sinus cavities and cause sinusitis. Similar to the cultures made from the middle ear, it has been shown that the pathogenic bacteria in the adenoid and the pathogenic bacteria detected in the discharge from the middle meatus near the anterior sinus drainage area are the same. For this reason, nasal surgery is the best treatment method for children with recurrent sinusitis attacks.
Adenoid face (long face syndrome)
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| In the photo above, there is a side view of a boy who is forced to breathe with his mouth open due to adenoid hypertrophy that closes the choanas close to 100%. He has an appearance of being sluggish, unconscious and making a breathing sound. |
Adenoid Hypertrophy - Diagnosis
Adenoid is lymphoid tissue located at the back of the nostrils. It is not possible to be seen by patients and non-otolaryngologists by examination. It can be seen during the endoscopic intranasal examination. It can also be evaluated indirectly with imaging tools such as lateral radiography, magnetic resonance imaging and tomography. In addition to all tonsil surgeries performed on children, adenoidectomy is also performed. In addition, adenoid surgery (adenoidectomy) can be performed alone or in conjunction with ear tube placement surgeries.
Warnings and Precautions For Adenoid Hypertrophy
Adenoids are in lymphoid structure. It is generally thought that these tissues can grow by giving an exaggerated response to foreign particles, microbes and allergens in childhood. Genetic predisposition, crowded environment and breathing polluted air increase the risk of adenoid enlargement. You can take the following measures to prevent your child's adenoid from growing:
If your child goes to a crowded environment such as a nursery, be sure to wash the nose with salty sea water after returning from the nursery. When the child bows his head forward, let the water flow up to the back of the sink in the sink and teach your child to spit the water coming from behind. You can do the intranasal washing procedure to your child at night and when he first gets up in the morning.
Keep your child away from environments with cigarette smoke, dusty, damp and wet moldy walls, and large quantities of industrial products.
Pay attention to allergy treatment. Although there are studies showing that spraying cortisone into the nose may have an inhibitory role in nasal growth; this issue is controversial.
It is important to have an ENT specialist who follows your child for upper respiratory tract infections. Adenoid enlargement may not be easily understood by patients.
There is no proven herbal medicine for adenoid growth. If your child is not allergic to menthol and eucalyptus, upper respiratory tract infections can be treated faster with hot steam application containing these products. A herbal medicine should not be dropped into the nose without consulting your doctor.
The History of Adenoidectomy Operation
At the end of the 1800s, it was stated by Willhelm Meyer from Copenhagen, Denmark that the adenoid might be responsible for the complaints and hearing loss related to the nose, and afterwards, nasal surgery was started. Tonsil surgery (tonsillectomy operation), one of the most common operations, has been performed for at least 2000 years. Since the early 1900s, adenoid surgeries in children have been performed together with tonsil surgeries. Interestingly, these two surgeries have been accepted as a treatment tool for the treatment of anorexia, mental retardation and enuresis (many different health problems may occur in patients with tonsil and adenoid enlargement or frequent infections).
It was emphasized that in children who had nasal surgery, ear fluid was treated, delay in speech and mental retardation were prevented.
In children with adenoid hypertrophy and not treated for a long time, especially middle ear fluid; ear and sinus diseases can be seen. Consequently, children may be affected negatively in hearing and speech development. Again, in children with adenoid, a facial expression appears as if the mouth is open and there is difficulty in perception (adenoid face). In the 1930s and 1940s, the incidence of nasal surgery decreased due to the introduction of antibiotics and effective treatment of childhood infections.
Adenoidectomy Indications
In Which Situations Is Adenoidectomy Performed?
Adenoids are lymph nodes located behind the nose. Enlarged and infected adenoid tissue may cause nasal congestion and sinusitis by preventing drainage of the sinuses. Apart from these, it may cause recurrent ear infections by closing the mouth of the eustachian tube or becoming a germ reservoir. When a solution cannot be found with medical treatment, adenoidectomy is usually performed to alleviate these problems. Adenoid surgery is rarely required in adults, as the size of the adenoid decreases during puberty.
The situations in which nasal surgery is necessary can be summarized as follows:
Respiratory Problems
Large adenoids can block the airway in children. Children with this problem usually breathe through the mouth and snore loudly. Occasionally, even breathing pause (sleep apnea) can be seen. This is a very common indication for adenoid surgery in children. Adenoid surgery will help the child's respiratory tract to relax and a better quality of sleep.
In the above two separate radiographs (adenoid x-ray - adenoid radiography - lateral cranial graphy with soft tissue dose), in the left one, adenoid tissue was seen in the nazaopharynx region, which does not narrow the air passage too much; Adenoid tissue (Adenoid enlargement - Adenoid hypertrophy) is seen in the nasal area on the right, which narrows the air passage considerably. This second patient had complaints such as sleeping with an open mouth, snoring, frequent sinus and otitis media due to adenoid enlargement, and adenoid surgery was planned. You can see them in large size by clicking on the photos.
Recurrent Ear Infections
The enlarged adenoid can sometimes close the eustachian tube, a tube that connects the middle ear to the back of the nose. When the eustachian tube is blocked, the fluids in the middle ear cannot be drained, so infection and fluid accumulation in the middle ear may occur. In these cases, nasal surgery will reduce the number of ear infections. Adenoidectomy surgery is useful if a child has five or more ear infections a year.
Sinus Infections
Enlarged and infected adenoid tissue may cause sinusitis by obstructing the nasal airway, becoming a germ reservoir and preventing the drainage of the sinuses. In children with long-term sinusitis, nasal surgery will help reduce the frequency of sinus infections.
Tonsillitis
Adenoid surgery is indicated for children with attacks of tonsillitis (tonsillitis). Adenoid surgery is performed together with tonsil surgery (tonsillectomy) in children with recurrent tonsillitis.
Adenoid Removal Surgery Details
OperationTechnique
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| Adenoidectomy technique - classical curettage |
Adenoidectomy is performed under general anesthesia. It should be noted that there is no palate or cleft lip in the mouth after the automatic retractor is attached to the mouth, which separates the upper and lower teeth. Adenoid surgery is performed under general anesthesia. After the automatic mouth retractor is placed and the palate is stretched, the adenoid is removed with the help of curettes called adenotome. During the scraping (or curetting) process, the eustachian tube mouths should not be damaged at the opening of the eustachian tubes. After the curettage, bleeding is controlled and the operation is terminated. Electrosurgical devices for tonsillectomy and adenoidectomy developed for adenoid surgery (Source: Endoscopic-assisted adenoidectomy), adenoid surgery and tonsil surgery (Source: Electrosurgical devices for tonsillectomy and adenoidectomy), adenoid surgery with "coblation" technology ( Source: Coblation Total Tonsillectomy and Adenoidectomy ...), adenoid surgery with "Suction diathermy" technique (Source: Suction diathermy adenoidectomy ...) and similar techniques are described. However, the most common application is the classical curettage technique.
Adenoid Removal Surgery (Adenoidectomy Operation) Video
Adenoidectomy Cost in Istanbul
The price of adenoidectomy operation varies between $ 1750 (in hospitals with affordable prices) - $ 3000 (in hospitals with luxury and jci accreditation), depending on the hospitals and the materials used. 1-day hospitalization, blood tests are included in this fee. Generally, patients are discharged 4 hours after the operation.
About Pain After Adenoidectomy
Since the skin incision is not made during the operation and the tonsils are not touched, it is not expected to be a pain. Since an oral intubation tube is placed during anesthesia and the soft palate is stretched during the surgery, the nasal area is made visible, there may be pain in the throat area that lasts for 1-2 days.
Risks and Complications of Adenoidectomy Operation
Although very rare, the following complications may occur after adenoid surgery:
- Bleeding: It usually stops spontaneously or with simple intervention. It occurs more frequently in adult patients who have had adenoid surgery.
- Middle ear inflammation: It is seen as a result of the infection occurring in the adenoid region reaching the ear through the eustachian tube. It is a very rare complication.
- Nasopharyngeal cicatricial stenosis (permanent stenosis in the nasal area): It occurs as a result of excessive mucosal damage, nasal surgery while there is infection and removal of the lateral pharyngeal bands. Again, it is a very rare complication. Apart from the velopharyngeal insufficiency I mentioned above, there are risks related to bleeding, infection and anesthesia, which generally belong to surgical procedures. It has been reported in ancient sources that nasopharyngeal stenosis (adhesion and narrowing of the nasal passage) can be seen as a result of circular mucosa damage.
- Hypernasal speech (air leakage into the nose when talking): After the adenoid removal, velopharyngeal insufficiency occurs as a result of excessive increase in the distance between the soft palate and the nasal passage (velopharyngeal space) and air escapes into the nose while talking. Apart from this, after tonsil and adenoid surgery, air may come from the nose temporarily as a result of the decrease in movement due to pain in the palate and the inability to use the soft palate muscles. Generally, this situation resolves spontaneously within weeks.
Patient Care After Adenoidectomy
Since the operation is performed under general anesthesia, oral nutrition is not given for the first 4 hours after surgery.
In the first few days after the operation, hot and hard foods should not be consumed. Foods such as warm milk, ice cream, soup, fruit juice, pudding and pudding are ideal. A few drops of blood can come from the nostrils. The reason for this is minor bleeding in the nasal area. However, if fresh red blood comes from the mouth or nose, consult a doctor immediately.
Current studies after adenoid surgery do not recommend the use of antibiotics as a standard. Antibiotics may also be prescribed if your doctor deems it necessary.
In case of postoperative pain, only painkillers are recommended.
Irrigation the nose with ocean waters can accelerate the healing as it provides removal of scabs and bacteria from the operation area.
When the ocean waters are not used, the odor from the nose and mouth of the patients can be noticed after nasal surgery. Especially during surgery, the odor can be noticed after a few days after the surgery due to the radiofrequency application for bleeding control (usually radiofrequency is rarely used) However, this situation is not a temporary and dangerous situation. If the bad breath that occurs after the surgery increases day by day and continues after the first week, the doctor who performed the surgery should be consulted.
Contraindications For Adenoidectomy Operation
Adenoid surgery is performed under general anesthesia and the patient's head is tilted backwards. Adenoid surgery may be inconvenient in the following situations:
- Having a disease that may cause bleeding disorder or having to use medication.
- Relative contraindication exists in the presence of hypotonia of the palate associated with short palate, submucous cleft palate, velocardiofacial syndrome or Kabuki syndrome, large velopharyngeal space (distance between the palate and the anterior nasopharyngeal wall on the posterior aspect). Partial adenoidectomy (limited adenoid surgery) can be performed to prevent a problem associated with excessive air leakage, called "velopharyngeal insufficiency" and when talking.
- Atlantoaxial joint laxity (seen in 10% of children with Down syndrome). Nasal surgery can be performed in the neutral position or after the stability of these two joints is achieved by neurosurgery.
Surgery in neutral position by neurosurgery or the following stabilization can make it possible to perform surgery without harming the patient
Adenoid surgery age
Adenoid surgery is generally performed on children between the ages of 2 and 6. Old sources argue that adenoid surgery should not be performed before the age of 3 unless it is necessary. Most physicians prefer to operate up to the age of 3, considering risks such as anesthesia risks and the sudden increase in oxygen intake due to surgery. In addition, nasal surgery can be performed under 3 years of age in children with severe sleep apnea syndrome, middle ear infections and sinusitis resistant to medical treatment, and PFAPA syndrome resistant to medical treatment.
Adenoids can grow again after surgery!
The earlier adenoid surgery is performed in children, the higher the risk of re-growth of the adenoid. In an article about Kou, it was emphasized that there is a risk of recurrence of adenoid after adenoid surgery performed in children under 5 years of age. In the same study, Yin was found to be much more likely to recur after adenoid surgery under 2 years of age. In fact, the logic is very simple, if the nasal surgery is performed during the period when the immune system is raging and the lymphoid structures around the upper respiratory tract continue to grow, the likelihood of recurrence will be high.
There is no special bacteria culture for adenoid hypertropy!
There is no bacterial culture or routine laboratory test that needs to be done specifically for adenoid growth.
Is it possible to completely remove adenoids?
There are deep parts of the adenoid. In adenoid surgeries, most of the adenoid is removed and the tissue of the adenoid remains partially at the bottom. Attempting to perform deep resection can cause excessive mucosal damage and bleeding.
Benefits of adenoid surgery
In addition to removing a mass lesion that causes nasal obstruction and associated symptoms with adenoid surgery, mechanically reducing airway resistance; It is the removal of the part of the adenoid that is the germ respiration and the "cleaning" of the nasal passage. In other words, nasal surgery means both relief of the air hole and cleaning of the germ reservoir.
It is expected to have different benefits such as:
- decreased frequency of recurrent middle ear, sinus and respiratory tract infections
- preventing structural adverse effects on the jaw and teeth in a possible long time
- increase in sleep quality
- decrease in stress hormones in the blood
- decrease in drug use frequency
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul
Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52
Appointment Phone: +90 212 561 00 52
Fax: +90 212 542 74 47
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