Summary for adenoidectomy to include anatomy, physiology, step-by-step descriptions, side effects, and complications:

Adenoid tissue is lymphoid tissue that sits in the back of the throat, behind and above the soft palate (behind the nasal cavity).

Surgery to shrink or remove the adenoid tissue is known as adenoidectomy.

The child has a breathing tube is placed in the mouth (oral intubation).

The adenoid tissue is then removed using one or more of the techniques (cold steel or hot temperature instruments).

The patient is then extubated (the breathing tube is removed).

The main effect is improved breathing and fewer ear infections.

Complications are not common but include bleeding, infection and incomplete closure of the throat during speech and swallowing.

Airflow through the mouth before an adenoidectomy. CamachoMD.com
Airflow through the mouth before an adenoidectomy.

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Background:

Anatomy/Physiology

What are adenoids?

Adenoid tissue is a group of lymphoid tissue, that is part of the immune system and it sits in the back of the throat, behind and above the soft palate (behind the nasal cavity).[1]

Lymphoid tissue can be found throughout the body.

Upper airway with the black arrow pointing to the adenoids (which are enlarged). CamachoMD.com
Upper airway with the black arrow pointing to the adenoids (which are enlarged).

Why is an adenoidectomy performed?

Typically an adenoidectomy is recommended in children who have nasal congestion or blockage (obstructed nasal breathing) to the point that they are symptomatic (such as have chronic mouth breathing or recurring ear infections).

The typical child who is referred for an adenoidectomy has tried medical management and has failed it.

The main goal of adenoidectomy is to help improve the nasal breathing of a child (teenagers or adults in some cases).

Adenoid tissue sits in the back of the nose, therefore, enlarged adenoid tissue can cause obstruction of the upper airway during breathing while awake (nasal obstruction) and during sleep (snoring and sometimes obstructive sleep apnea).

Additionally, the adenoid tissue sits near the opening of the Eustachian tube which connects the ears to the nose.

Adenoidectomy is commonly combined with either pressure equalization tube placement (for ear infections, or fluid in the middle ears) or with a tonsillectomy depending on the child’s conditions. 

Airway blockage before adenoidectomy, note that some air might get through, but sometimes the children can breathe through their noses. CamachoMD.com
Airway blockage before adenoidectomy, note that some air might get through, but sometimes the children can breathe through their noses.

How are adenoidectomies performed (step-by-step) in the operating room?

Before surgery:

A child needs to either not eat after midnight or needs to follow the guidance given by the anesthesia provider who saw them before surgery.

Some anesthesia providers allow for the child to have clear liquids a few hours before the planned surgery, but it can vary, so you need to double-check.

The child is then brought to the hospital, usually 2-3 hours before the planned surgery start time.

The otolaryngologist (ear, nose and throat surgeon) will then meet the patient and their parents/guardians in the preoperative holding area.

The consent is verified and the armband is reviewed for accuracy of the name and the birthdate or other identifiers. Another armband is usually placed on the child’s wrist stating the surgical site (adenoids).

The anesthesia provider and the operating room nurse will then meet the patient.

In the operating room:

The patient is brought back to the operating room, and sometimes, the parents/guardians are also allowed to come back (depends on the anesthesia provider and specific circumstances).

The child is then placed onto the operating room table and masked anesthesia is given so they can go to sleep.

Once the patient is asleep, an intravascular (IV) catheter is placed.

This also depends on the child’s age since older children may tolerate an IV catheter being placed while awake.

The child is given IV anesthetic medications.

Placement of a breathing tube (intubation):

The child is intubated orally with the anesthesia provider using a laryngoscope to see the vocal cords and the endotracheal tube (breathing tube) is inserted with direct viewing of the larynx (voice box).

Once intubated, a timeout is called to verify the name of the child, the birthdate, the procedure, and several safety items.

The oxygen is lowered to room air (21%) so that the risk of an airway fire is decreased dramatically.

Intubation in a patient for throat surgery. BladeMD.com
Intubation in a patient for throat surgery.

The surgical portion of the adenoidectomy:

The soft palate is then evaluated for a submucous cleft or a bifid uvula. Either one of these would result in a more conservative adenoidectomy in order to minimize the chance of velopharyngeal insufficiency (a disorder in which the throat doesn’t close off properly and air and liquid can escape from the nose).

From here, one of two techniques is performed, either the adenoidectomy is performed by going through the mouth (transoral approach) or through the nose itself (a transnasal endoscopic approach which is less common).

The adenoidectomy typically takes between 10-30 minutes.

How is the traditional, transoral approach to an adenoidectomy performed step-by-step?

A red rubber catheter is placed into one of the nostrils and is used to suspend the soft palate so that the adenoids can be seen with a mirror.

A mirror is then used to visualize the adenoid pad.

Adenoidectomy in a child. The adenoids are large. The surgeon is using a mirror to look at the adenoids through the mouth. BladeMD.com
Adenoidectomy in a child. The adenoids are large. The surgeon is using a mirror to look at the adenoids through the mouth.

A tool is then selected to remove the adenoids.

Some tools remove the adenoids in larger pieces, and other tools remove the adenoids a small amount at a time.

Once the adenoidectomy is completed, the bleeding is stopped and the patient is then suctioned (throat and stomach).

The child is then turned back to the anesthesia provider for wakeup (and removal of the breathing tube).

Side Effects      

In the short-term, there may be an increase in congestion, a mild runny nose, and a low-grade fever.

The main effect of surgery in the long-term is the improvement in nasal breathing and fewer ear infections. In some children, snoring and obstructive sleep apnea could improve.

Remnant adenoid tissue after adenoidectomy. The adenoid tissue is shown with the blue arrow pointing to it. CamachoMD.com
Remnant adenoid tissue after adenoidectomy. The adenoid tissue is shown with the blue arrow pointing to it.
Airflow through the nose after adenoidectomy. Note the blue arrow shows the path of the air through the upper airway. CamachoMD.com
Airflow through the nose after adenoidectomy. Note the blue arrow shows the path of the air through the upper airway.

Does performing an adenoidectomy cause problems with the immune system?

According to Rusetskii and colleagues, an adenoidectomy has “no adverse effects on children’s health conditions and the mechanisms of immune protection.”[2]

A study by Lan and colleagues found that although there is a decrease in the levels of immunoglobulins (antibodies in the immune system or proteins that help fight infections), the level can be restored to the preoperative level in 90 days. [3]

Complications

What are complications after an adenoidectomy?

The complication rate for adenoidectomies is generally low.

Bleeding after an adenoidectomy:

A study by Lin and colleagues found that bleeding after surgery was about 0.28%.[4]  The study also found that the revision rate was 0.61% for children ≤4 years old, 2.06% for children 4-12 years old and 2.56% for children 12-18 years old.[4]

Infection after an adenoidectomy:

A review article found that adenoidectomy seems to have a beneficial effect on the bacteria that are found in the back of the nose after surgery (nasopharyngeal flora).[5]

Incomplete closure of the back of the throat after an adenoidectomy:

In some children, the back of the throat (palate and uvula) might not close properly after surgery. This could be seen during speech or swallowing in a disorder known as velopharyngeal insufficiency (VPI).

After adenoidectomy with tonsillectomy, the VPI risk was about 14% at 3 weeks, but it resolves by 5 months.[6]

After adenoidectomy, the risk of VPI is about 3% at 3 weeks.[6]

The risk of VPI after adenoidectomy or adenoidectomy with tonsillectomy at 5 months is about 0.3% (1 in 300 patients).[6]

Frequently asked questions:

How common is an adenoidectomy?

About 25 per 100,000 children have an adenoidectomy without tonsillectomy.[4] [7]

If you consider adenoidectomy with tonsillectomy, then the rate is about 53 per 100,000.[7]

How much of the adenoids can be removed?

Generally speaking, there is a balance between leaving too much adenoid tissue (risking regrowth) and taking too much tissue and getting into the muscle underneath the adenoid pad.  Each surgeon will tailor the surgery to the needs of the patient.

There are a few circumstances in which a partial adenoidectomy is recommended, such as in children who have bleeding disorders, children with a bifid uvula, submucous cleft palate and/or an actual cleft palate.[8]

In patients with a cleft palate, a partial adenoidectomy is recommended. A systematic review by Ingrid and colleagues found that surgeons would remove “the upper half”, remove tissue that is obstructing the airway near the back of the nose and then leave tissue so that the palate can close off appropriately (leaving about 30% of the adenoid).[8]

Why do children need to be intubated (have a breathing tube) when they undergo an adenoidectomy?

Children need to be under general anesthesia in order to do an adenoidectomy.

General anesthesia is when the child is not aware of their environment (fully asleep) and is breathing comfortably (while intubated and having the breathing tube).

The general anesthesia with intubation allows for the ENT surgeon to open the patient’s mouth and use a mirror to take out the adenoids. Because there will be some bleeding, the ENT surgeon needs to cauterize or stop the bleeding.

Why do ear, nose and throat surgeons sometimes recommend holding off on the tonsillectomy in younger children (e.g. toddlers)?

Ear, nose and throat surgeons may advocate for adenoidectomy alone in younger children because of the risks of bleeding and pain.

Bleeding in younger children (such as in toddlers) can be more problematic because they have a smaller volume of blood, to begin with, so if they bleed, it is proportionally larger than it is in older children or adults.

Additionally, a review article by Dr. Reckley and colleagues demonstrated that adenoidectomy alone can help reduce obstructive sleep apnea in select children, especially those who have large adenoids and are age 2 and under.[9]

Does adenoidectomy alone help improve obstructive sleep apnea?


Dr. Reckley and colleagues found that an adenoidectomy alone can improve obstructive sleep apnea, with a 57-95% reduction in the apnea-hypopnea index (number of blockages of the upper airway per hour) and can improve the oxygen saturation by 5.5% (from 80 to 85.5%).[9]

The study also found that the children who had the most improvement in obstructive sleep apnea are children who were under 12 months of age.[9]

When should someone not have an adenoidectomy?

If the adenoids have not been evaluated and it is the only surgery that is being performed, then it is unclear why an adenoidectomy is being recommended.

Generally, there is a reason for the adenoidectomy. For example, if a child has nasal obstruction or congestion and has a nasal scope (flexible fiberoptic nasopharyngoscopy) and the ENT surgeon sees large adenoids and there are no other reasons identified, then an adenoidectomy may be recommended.

How is the transnasal endoscopic approach to an adenoidectomy performed step-by-step?

Endoscopic sinus surgery equipment is used. A zero-degree endoscope (a scope that lets allows the surgeon to see the operative site directly in front of them).

Most of the instruments that can be used when performing a transoral adenoidectomy can be used to perform the adenoidectomy can be used through the transnasal approach.

In some cases, the otolaryngologist may combine a transnasal and transoral approach in which the adenoids are reduced by directly viewing the adenoid tissue through the nose, but the instruments to reduce the size of the adenoids are placed through the mouth.

What happens in the operating room after the adenoid tissue is removed?

Once the otolaryngologist has stopped any bleeding (after either the transoral or transnasal approach), the patient is suctioned in the nose and throat.

A tube (orogastric tube) is then passed to suction out the stomach contents since some of the water or blood during the surgery can be swallowed and that can make the patient nauseated after surgery.

Does the technique used for an adenoidectomy make a difference?

A study by Ferreira and colleagues compared a blind curettage, to video-assisted adenoidectomy using coblation and video-assisted adenoidectomy using a microdebrider.[10] 

The authors found that the blind curettage was the fastest, however, all three techniques resulted in an improved quality of life and there were no major complications regardless of the technique used.[10]

What is the cost to evaluate the adenoid size?

Lateral cephalograms cost about $605 and flexible nasopharyngeal endoscopies cost about $654.[11]

What is the Common Procedure Terminology (CPT) Code for Adenoidectomy?

The CPT Codes are:

First adenoidectomy (primary adenoidectomy)

  • 42830 for <12 years old
  • 42831 for 12 years and older

Second or repeat adenoidectomy (secondary adenoidectomy)

  • 42835 for <12 years old, and
  • 42836 for 12 years and older

References

1.            Mnatsakanian, A. and S. Sharma, Anatomy, Head and Neck, Adenoids, in StatPearls. 2019, StatPearls Publishing

StatPearls Publishing LLC.: Treasure Island (FL).

2.            Rusetskii, Y.Y., et al., [The immunological consequences and risks of adenoidectomy]. Vestn Otorinolaringol, 2018. 83(2): p. 73-76.

3.            Lan, Y.G., et al., [Effect of resection of adenoids and tonsillectomy on immune function in children with obstructive sleep apnea hypopnea syndrome]. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi, 2018. 32(10): p. 770-773.

4.            Lin, D.L., et al., The safety and risk factors of revision adenoidectomy in children and adolescents: A nationwide retrospective population-based cohort study. Auris Nasus Larynx, 2018. 45(6): p. 1191-1198.

5.            Aarts, J.W., et al., Alterations in the nasopharyngeal bacterial flora after adenoidectomy in children: a systematic review. Otolaryngol Head Neck Surg, 2010. 142(1): p. 15-20.e1.

6.            Khami, M., et al., Incidence and Risk Factors of Velopharyngeal Insufficiency Postadenotonsillectomy. Otolaryngol Head Neck Surg, 2015. 153(6): p. 1051-5.

7.            Bhattacharyya, N. and H.W. Lin, Changes and consistencies in the epidemiology of pediatric adenotonsillar surgery, 1996-2006. Otolaryngol Head Neck Surg, 2010. 143(5): p. 680-4.

8.            Salna, I., et al., Partial Adenoidectomy in Patients With Palatal Abnormalities. J Craniofac Surg, 2019. 30(5): p. e454-e460.

9.            Reckley, L.K., et al., Adenoidectomy can improve obstructive sleep apnoea in young children: systematic review and meta-analysis. J Laryngol Otol, 2016. 130(11): p. 990-994.

10.          Ferreira, M.S., et al., Comparison of three different adenoidectomy techniques in children – has the conventional technique been surpassed? Int J Pediatr Otorhinolaryngol, 2018. 104: p. 145-149.

11.          Lertsburapa, K., J.W. Schroeder, Jr., and C. Sullivan, Assessment of adenoid size: A comparison of lateral radiographic measurements, radiologist assessment, and nasal endoscopy. Int J Pediatr Otorhinolaryngol, 2010. 74(11): p. 1281-5.