Results
This study included 48 patients who underwent adenotonsillectomy of which 8 patients had adenoidectomy only. The study sample consisted of n=31 (64.6%) male and n=17 (35.4%) female patients. The mean age of patients was 6.125 and the range of age was (2–14) years; the standard deviation of age (SD) was 3. Further details for each group are described in Table I.
In Group A, patients underwent adenoidectomy with laryngeal mirror assistant: n=25 (52.1%), while in Group B, patients underwent adenoidectomy without laryngeal mirror assistant: n=23 (47.9%). Adenoid remnants were found in 22 patients, who were examined by a fiber optic camera six weeks postoperatively, and the location was in the pharyngeal roof and near the choanal opening in 19 (39.6%) patients (grade 1). Adenoid remnants were also found along and touching the torus tubarius in 3 (6.3%) patients (grade 2). We did not encounter any patient in the first 6 weeks of follow up with grade 3 or grade 4. Mouth breathing and snoring were both reported in 6 (12.5%) patients, one patient had only snoring without mouth breathing, and one patient had mouth breathing without snoring.
Regarding the association between study group and adenoid remnant presence, it was found that five patients (20%) in Group A had adenoid remnants of grade 1, while 20 (80%) patients had grade 0. Group B included 14 (60.9%) patients who had grade 1, 3 (13%) patients had grade 2, and 6 (26%) patients had grade 0. Analysis of data by Fisher chi-square test showed a statistically significant association between Group A and Group B, regarding incidence of adenoid remnants. Consequently, Group A presented higher percentage of grade 0. X2 (2) =14.82, p≤0.001, in addition we found that the Cramer’s V for effect size showed a moderate association between two variables. (Table II).
The analysis of the association between obstructive symptoms (snoring and mouth breathing) between each group in this study found that Group A included 3 (12%) patients who complained of snoring after six weeks of surgery, while in Group B, 4 (17.4%) patients experienced snoring. The results showed that there were no statistically significant association between study groups and presence of snoring. (p-value=0.696) (Table III).
On the other hand, Group A included 2 (8%) patients who had mouth breathing during sleep, whereas Group B had 5 (21.7%) patients. The results showed that there were no statistically significant associations between study groups and presence of mouth breathing. (P-value=0.273) (Table IV).
Table I: Summary table of sociodemographic characteristics of
patients.
|
Group
|
Males
n (%)
|
Females
n (%)
|
Total
n
|
Age
mean (SD)
|
|
A(mirror)
|
17(68)
|
8(32)
|
25
|
5.96(2.94)
|
|
B (no mirror)
|
14(60.8)
|
9(39.2)
|
23
|
6.4(2.9)
|
Table III: post-operative snoring and its association with each group. Fisher
chi square analysis results frequency, percentage and p-value are displayed.
|
Group
Symptom
|
Group A
n (%)
|
Group B
n (%)
|
p-value
|
|
Snoring
|
3(12)
|
4(17.4)
|
0.696
|
|
No Snoring
|
22(88)
|
19(82.6)
|
Table IV: post-operative mouth breathing and its association with each
group. Fisher chi square analysis results frequency, percentage and p-value are
displayed.
|
Group
Symptom
|
Group A
n (%)
|
Group B
n (%)
|
p-value
|
|
Mouth breathing
|
2(8)
|
5(21.7)
|
0.237
|
|
No mouth breathing
|
23(92)
|
18(78.3)
|
Discussion
Adenoid hypertrophy is the most common cause of upper airway obstruction in pediatric patients; therefore, adenoidectomy is the surgical procedure of choice to relieve these symptoms and improve patients’ quality of life and prevent the medical sequelae of upper airway obstruction (10). Recurrence or persistence of obstructive symptoms can happen after surgery. It could occur if the residual adenoid tissue in choanal opening, pharyngeal roof or torus tubarius remained after the surgery. In this case, persistent obstructive symptoms could emerge. In this study, our patients were reviewed after 6 weeks, to figure out the association between persistence of obstructive symptoms and existence of adenoid remnants.
Complete resection of adenoid tissue could decrease the risk of early post-operative complications. Therefore, a good visualization of adenoid tissues intraoperatively, by using different tools like mirrors or endoscopes, decrease the frequency of adenoid remnants, which is considered a paramount factor to decrease the risk of primary adenoids bleeding that occurs within 24 hours of the surgery (16). Moreover, using assistant tools will make the procedure safer, as under direct vision, can avoid damaging vital adjacent structures like eustachian tube orifice and decrease the possibility of eustachian tube dysfunction, which is detected by early presentation of ear symptoms like otalgia and aural fullness or by abnormal tympanometry test results (17). Furthermore, direct visualization can also avoid injury to submucosal plane or deeper muscle tissue and decrease the risk of intraoperative bleeding (18).
The decision to choose between each visualization tool depends on the surgeon’s preference; however, each tool has its own advantages. For instance, the laryngeal mirror is a cheaper tool, readily available, and it does not require to approach the adenoids through the nose like endoscopes, which could result in synechia and crusting, especially if powered instruments are used for adenoidectomy like microdebrider. Additionally, in significant proportion of patients, it is difficult to get access through the nose if there is deviated nasal septum or inferior turbinate hypertrophy (19).
Hypertrophied adenoid remnants beside other rhinogenic factors like allergic rhinitis may cause recurrent symptoms, which need longer time to occur. Hence, it is recommended to evaluate the association between the risk of residual adenoid tissue re-growth and the risk of recurrence of obstructive upper airway symptoms after several months to years of surgery(12). Revision adenoidectomy incidence and the main underlying factors associated with it have been studied previously. Grindle et al. studied the incidence of revision adenoidectomy among 23,612 patients in a 5-year period. The rate was 1.3%, and the most common indication in revision cases was adenoid hypertrophy. A 2008 study by Joshua et al. on long-term follow-up after adenoidectomy failed to define a specific rate for revision adenoidectomy but suggested that adenoid regrowth or persistence is related to the surgical difficulty encountered due to the indirect access to the adenoid pad (20). In another study, the incidence of adenoid regrowth was 19.1% within a 12–24-month period. It was discovered that the incidence was higher in children below 5 years of age and in those patients who were treated postoperatively with antibiotics on numerous occasions (12).
In a study by Emerick et al, the authors concluded that there was a significant association between tubal tonsillar hypertrophy in previously operated patients and the recurrent and persistent symptoms;
they identified residual adenoid tissue as a recognized potential risk (21); However, in our study, residual adenoid tissue was significantly higher in Group B that comprised 3 patients with grade 2 (adenoids remnants in torus tubarius), but Group A did not comprise any patients with grade 2.
Laryngeal mirror is a cheap instrument, and we believe it is ideal to be used in adenoidectomy to assist in visualizing adenoid tissue in hidden anatomical areas like nasopharyngeal roof and along torus tubarius. Ark et al., in a study, found that only 20% of patients had no residual tissue after blunt curettage and digital palpation, after which a laryngeal mirror was used to remove residual adenoid tissue. Then, the median proportion of residual adenoid tissue volume to total adenoid tissue volume was calculated, which was 19.98% (4); However, we also have to consider nasal endoscopy for intraoperative evaluation, especially in patients with a history suggestive of adenoidal hypertrophy where mirror examination of posterior choana was negative (22).
The limitations of the study were the subjective assessment of obstructive symptoms postoperatively and the short follow up period. More patients need to be studied to reach a firm conclusion to abandon the blind classical curettage approach to removed adenoidal tissue.
Conclusion
This study concluded that using a laryngeal mirror as an assistant direct visualization tool during adenoidectomy procedures decreased the rate of residual adenoid tissue postoperatively in comparison to a blind indirect method. However, we encountered negative association between obstructive symptoms persistence and laryngeal mirror approach during 6 weeks of follow-up. Nevertheless, the laryngeal mirror assistant is efficient, cheap and a valuable instrument to visualize adenoid tissue precisely; hence, we recommend practicing it routinely.
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