Adenoidectomy
Encyclopedia
Adenoidectomy is the surgical
removal of the adenoid
s. They may be removed for several reasons, including impaired breathing through the nose and chronic infections or earaches. The surgery is less common for adults. It is most often done on an outpatient basis under general anesthesia
. Post-operative pain is generally minimal and prevented with an abundance of icy or cold foods. Spicy foods, such as jalapeños or curries
, should be avoided. The procedure can sometimes be combined with a tonsillectomy
if needed. Recovery time can range from several hours to two or three days (though as age increases so does recovery time).
Adenoidectomy is not often performed on children under 1 year old as adenoids help the body's immune system but their value decreases rapidly once children reach this age. Adenoids become vestigial organs in adults.
to remove adenoid tissue by William Meyer in 1867. By the early 1930s the operation became nearly universal in children of school age.
Adenoidectomies began to be routinely performed together with tonsillectomies in the early 1900s. Initially, the procedures were performed by otolaryngologists, general surgeons, family practitioners and general physicians but over the past 30 years it became common that tonsillectomies and adenoidectomies are performed almost exclusively by otolaryngologists.
Adenoidectomies were indicated in cases of anorexia nervosa
, mental retardation
, enuresis
or for one's well-being and to promote good health. At this time, the indications may seem odd, they may be explained as children may fail to thrive if they have chronically sore throat
s or severe obstructive sleep apnea (OSA). Obstructive sleep apnea is a medical condition that has been related to enuresis. Also, children who hear poorly because of chronic otitis media
may have speech delay
and be mistaken for mentally retarded. Adenoidectomies help resolve ear fluid problems, speech delays, and perceptions of low intelligence
. Enuresis has actually been studied and listed as an indication for tonsillectomy and adenoidectomy (T&A) because large tonsils and adenoids block normal breathing through the nose and mouth, which interrupts sleep architecture and decreases normal brain and brainstem control of urinary function.
The incidence of the procedure declined starting with the 1930s as the use of the procedure became controversial. Treating tonsillitis and adenoiditis became easier and no longer required surgery as antimicrobial agents were developed and it is obvious that the upper respiratory infections were going through a decline among the older school-aged children. Also, at that time several studies showed that adenoidectomies and tonsillectomies were ineffective as well as the existence of an increased risk of developing poliomyelitis
. Once the opinion pendulum began to swing towards avoidance of surgery, good prospective clinical trials, which have been performed over the last 2 decades, were required to prove to the medical and lay community that good indications for tonsillectomy and adenoidectomy (T&A), tonsillectomy alone, and adenoidectomy alone, exist.
The incidence of the procedure can clearly be observed for some decades ago, when the procedure was performed on an inpatient basis. According to the data recorded in 1971, more than 1 million Americans underwent tonsillectomies or adenoidectomies procedures, combined or alone, from which 50,000 consisted of adenoidectomy alone.
The existent data shows that by the late 1980s, the number or combined or single surgical procedures have decreased by 4 times, to 250,000 tonsillectomies and adenoidectomies. In 1987, the number of adenoidectomies alone decreased by more than three times, to 15,000.
However, this was the period when adenoidectomy started being performed on an outpatient basis and therefore it is now difficult to estimate an accurate number of procedures that are performed nowadays. In current practice, almost all adenoidectomies alone are performed in outpatient settings unless other issues or medical problems require hospital admission or an overnight stay..
Currently, adenoidectomy is indicated in children with obstructive adenoids, recurrent or chronic sinusitis
, recurrent or chronic adenoiditis or to prevent recurrent or chronic otitis media. The surgery is only contraindicated in cases when general anesthesia carries too many risks for a patient's health.
Adenoids develop from a subepithelial infiltration of lymphocytes after the embryo gets into the 16th week. Adenoids are a part of the Waldeyer ring
of lymphoid tissue together with the palatine tonsils and the lingual tonsils. On histology, the tonsils contain 10–30 crypts lined by antigen processing stratified squamous epithelium and they have germinal centers as in other lymph tissue.
After birth, adenoids begin to enlarge and they keep growing until the individuals are aged 5 to 7 years. It is common that in infants of 18 to 24 months the adenoids are symptomatic, meaning that snoring, nasal airway obstruction and obstructed breathing usually occur during sleep. Over time, adenoids become gradually asymptomatic as when children reach school age, adenoids are expected to begin to shrink and when they reach teenage years, the adenoids should become small enough to not cause any symptoms.
The establishment of the upper respiratory tract
is initiated at birth. Species of bacteria such as lactobacilli, anaerobic streptococci, actinomycosis
, Fusobacterium species, and Nocardia
are normally present in children of 6 months old. Normal flora found in the adenoid consists of alpha-hemolytic streptococci and enterococci, Corynebacterium species, coagulase-negative staphylococci, Neisseria species, Haemophilus species, Micrococcus species, and Stomatococcus species.
Infection of the adenoids can lead to the development of ear, nose and sinus illnesses.
The most common types of bacteria that affect the adenoids and cause infections in both children and adults are Haemophilus influenzae
, group A beta-hemolytic Streptococcus
, Staphylococcus aureus
, Moraxella catarrhalis
, and Streptococcus pneumoniea. Heamophilus influenza, Moraxella catarrhalis and Streptococcus pneumonia are the three most resistant pathogens of otitis and rhinosinisitis in children suffering from these diseases.
Adenoidectomies, no matter the size of the adenoids, improve the symptoms of rhinosinusitis and decrease the risks of recurrent or persistent middle ear effusions or infections in children older than 3 years. Also, in pre-menopausal adult women, an adenoidectomy can lead to a short term increase in breast mass.
In 1999, a presentation at the American Academy of Pediatrics
confirmed this concern by finding that adenoidectomy usually controlled symptoms and infections in children with large adenoids; however, if the adenoid was small and CT scan evidence of chronic sinusitis was present, not as many children improved, leading the authors to believe these children would benefit from initial procedures of adenoidectomy and endoscopic sinus surgery.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
removal of the adenoid
Adenoid
Adenoids are a mass of lymphoid tissue situated posterior to the nasal cavity, in the roof of the nasopharynx, where the nose blends into the throat....
s. They may be removed for several reasons, including impaired breathing through the nose and chronic infections or earaches. The surgery is less common for adults. It is most often done on an outpatient basis under general anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
. Post-operative pain is generally minimal and prevented with an abundance of icy or cold foods. Spicy foods, such as jalapeños or curries
Curry
Curry is a generic description used throughout Western culture to describe a variety of dishes from Indian, Pakistani, Bangladeshi, Sri Lankan, Thai or other Southeast Asian cuisines...
, should be avoided. The procedure can sometimes be combined with a tonsillectomy
Tonsillectomy
A tonsillectomy is a 3,000-year-old surgical procedure in which the tonsils are removed from either side of the throat. The procedure is performed in response to cases of repeated occurrence of acute tonsillitis or adenoiditis, obstructive sleep apnea, nasal airway obstruction, snoring, or...
if needed. Recovery time can range from several hours to two or three days (though as age increases so does recovery time).
Adenoidectomy is not often performed on children under 1 year old as adenoids help the body's immune system but their value decreases rapidly once children reach this age. Adenoids become vestigial organs in adults.
History
The early version of adenoidectomy involved using a ring forceps through the nasal cavityNasal cavity
The nasal cavity is a large air filled space above and behind the nose in the middle of the face.- Function :The nasal cavity conditions the air to be received by the other areas of the respiratory tract...
to remove adenoid tissue by William Meyer in 1867. By the early 1930s the operation became nearly universal in children of school age.
Adenoidectomies began to be routinely performed together with tonsillectomies in the early 1900s. Initially, the procedures were performed by otolaryngologists, general surgeons, family practitioners and general physicians but over the past 30 years it became common that tonsillectomies and adenoidectomies are performed almost exclusively by otolaryngologists.
Adenoidectomies were indicated in cases of anorexia nervosa
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
, mental retardation
Mental retardation
Mental retardation is a generalized disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors...
, enuresis
Enuresis
Enuresis refers to an inability to control urination. Use of the term is usually limited to describing individuals old enough to be expected to exercise such control.Types of enuresis include:* Nocturnal enuresis* Diurnal enuresis...
or for one's well-being and to promote good health. At this time, the indications may seem odd, they may be explained as children may fail to thrive if they have chronically sore throat
Sore throat
A sore throat or throat pain is a common physical symptom usually caused by acute pharyngitis, or throat inflammation, though it also occurs in a number of other situations, such as post trauma and in diphtheria. It can cause mild to extreme pain....
s or severe obstructive sleep apnea (OSA). Obstructive sleep apnea is a medical condition that has been related to enuresis. Also, children who hear poorly because of chronic otitis media
Otitis media
Otitis media is inflammation of the middle ear, or a middle ear infection.It occurs in the area between the tympanic membrane and the inner ear, including a duct known as the eustachian tube. It is one of the two categories of ear inflammation that can underlie what is commonly called an earache,...
may have speech delay
Speech delay
Speech delay, also known as alalia, refers to a delay in the development or use of the mechanisms that produce speech. Speech, as distinct from language, refers to the actual process of making sounds, using such organs and structures as the lungs, vocal cords, mouth, tongue, teeth, etc...
and be mistaken for mentally retarded. Adenoidectomies help resolve ear fluid problems, speech delays, and perceptions of low intelligence
Intelligence
Intelligence has been defined in different ways, including the abilities for abstract thought, understanding, communication, reasoning, learning, planning, emotional intelligence and problem solving....
. Enuresis has actually been studied and listed as an indication for tonsillectomy and adenoidectomy (T&A) because large tonsils and adenoids block normal breathing through the nose and mouth, which interrupts sleep architecture and decreases normal brain and brainstem control of urinary function.
The incidence of the procedure declined starting with the 1930s as the use of the procedure became controversial. Treating tonsillitis and adenoiditis became easier and no longer required surgery as antimicrobial agents were developed and it is obvious that the upper respiratory infections were going through a decline among the older school-aged children. Also, at that time several studies showed that adenoidectomies and tonsillectomies were ineffective as well as the existence of an increased risk of developing poliomyelitis
Poliomyelitis
Poliomyelitis, often called polio or infantile paralysis, is an acute viral infectious disease spread from person to person, primarily via the fecal-oral route...
. Once the opinion pendulum began to swing towards avoidance of surgery, good prospective clinical trials, which have been performed over the last 2 decades, were required to prove to the medical and lay community that good indications for tonsillectomy and adenoidectomy (T&A), tonsillectomy alone, and adenoidectomy alone, exist.
Frequency
Obtaining recent information about how often the procedure is performed is quite difficult mainly because this type of surgery is nowadays performed in outpatient basis, and in these cases data is not well recorded. However, many doctors believe that adenoidectomy and tonsillectomy are performed too often.The incidence of the procedure can clearly be observed for some decades ago, when the procedure was performed on an inpatient basis. According to the data recorded in 1971, more than 1 million Americans underwent tonsillectomies or adenoidectomies procedures, combined or alone, from which 50,000 consisted of adenoidectomy alone.
The existent data shows that by the late 1980s, the number or combined or single surgical procedures have decreased by 4 times, to 250,000 tonsillectomies and adenoidectomies. In 1987, the number of adenoidectomies alone decreased by more than three times, to 15,000.
However, this was the period when adenoidectomy started being performed on an outpatient basis and therefore it is now difficult to estimate an accurate number of procedures that are performed nowadays. In current practice, almost all adenoidectomies alone are performed in outpatient settings unless other issues or medical problems require hospital admission or an overnight stay..
Currently, adenoidectomy is indicated in children with obstructive adenoids, recurrent or chronic sinusitis
Sinusitis
Sinusitis is inflammation of the paranasal sinuses, which may be due to infection, allergy, or autoimmune issues. Most cases are due to a viral infection and resolve over the course of 10 days...
, recurrent or chronic adenoiditis or to prevent recurrent or chronic otitis media. The surgery is only contraindicated in cases when general anesthesia carries too many risks for a patient's health.
Etiology
The adenoids are crafted of lymphatic tissue, located in the back of the nose and, like the tonsils, they work to ward off infection and produce antibodies.Adenoids develop from a subepithelial infiltration of lymphocytes after the embryo gets into the 16th week. Adenoids are a part of the Waldeyer ring
Waldeyer's tonsillar ring
Waldeyer's tonsillar ring is an anatomical term describing the lymphoid tissue ring located in the pharynx and to the back of the oral cavity....
of lymphoid tissue together with the palatine tonsils and the lingual tonsils. On histology, the tonsils contain 10–30 crypts lined by antigen processing stratified squamous epithelium and they have germinal centers as in other lymph tissue.
After birth, adenoids begin to enlarge and they keep growing until the individuals are aged 5 to 7 years. It is common that in infants of 18 to 24 months the adenoids are symptomatic, meaning that snoring, nasal airway obstruction and obstructed breathing usually occur during sleep. Over time, adenoids become gradually asymptomatic as when children reach school age, adenoids are expected to begin to shrink and when they reach teenage years, the adenoids should become small enough to not cause any symptoms.
The establishment of the upper respiratory tract
Upper respiratory tract
The upper respiratory tract or upper airway primarily refers to the parts of the respiratory system lying outside of the thorax or above the sternal angle. Another definition commomly used in medicine is the airway above the glottis or vocal cords...
is initiated at birth. Species of bacteria such as lactobacilli, anaerobic streptococci, actinomycosis
Actinomycosis
Actinomycosis is an infectious bacterial disease caused by Actinomyces species such as Actinomyces israelii or A. gerencseriae. It can also be caused by Propionibacterium propionicus, and the condition is likely to be polymicrobial aerobic anaerobic infection.Actinomycosis occurs rarely in humans...
, Fusobacterium species, and Nocardia
Nocardia
Nocardia is a genus of weakly staining Gram-positive, catalase-positive, rod-shaped bacteria. It forms partially acid-fast beaded branching filaments . It has a total of 85 species. Some species are non-pathogenic while others are responsible for nocardiosis. Nocardia are found worldwide in soil...
are normally present in children of 6 months old. Normal flora found in the adenoid consists of alpha-hemolytic streptococci and enterococci, Corynebacterium species, coagulase-negative staphylococci, Neisseria species, Haemophilus species, Micrococcus species, and Stomatococcus species.
Infection of the adenoids can lead to the development of ear, nose and sinus illnesses.
Pathophysiology
Adenoids can harbor chronic infections and this way they may contribute to recurrent sinusitis and recurrent or persistent ear disease. The type and amount of pathogenic bacteria seem to vary based on the disease present and the age of the child. Also, enlarged adenoids and tonsils may lead to the obstruction of the breathing patterns in children, causing apnea during sleep.The most common types of bacteria that affect the adenoids and cause infections in both children and adults are Haemophilus influenzae
Haemophilus influenzae
Haemophilus influenzae, formerly called Pfeiffer's bacillus or Bacillus influenzae, Gram-negative, rod-shaped bacterium first described in 1892 by Richard Pfeiffer during an influenza pandemic. A member of the Pasteurellaceae family, it is generally aerobic, but can grow as a facultative anaerobe. H...
, group A beta-hemolytic Streptococcus
Streptococcus
Streptococcus is a genus of spherical Gram-positive bacteria belonging to the phylum Firmicutes and the lactic acid bacteria group. Cellular division occurs along a single axis in these bacteria, and thus they grow in chains or pairs, hence the name — from Greek στρεπτος streptos, meaning...
, Staphylococcus aureus
Staphylococcus aureus
Staphylococcus aureus is a facultative anaerobic Gram-positive coccal bacterium. It is frequently found as part of the normal skin flora on the skin and nasal passages. It is estimated that 20% of the human population are long-term carriers of S. aureus. S. aureus is the most common species of...
, Moraxella catarrhalis
Moraxella catarrhalis
Moraxella catarrhalis is a fastidious, nonmotile, Gram-negative, aerobic, oxidase-positive diplococcus that can cause infections of the respiratory system, middle ear, eye, central nervous system and joints of humans.-History:...
, and Streptococcus pneumoniea. Heamophilus influenza, Moraxella catarrhalis and Streptococcus pneumonia are the three most resistant pathogens of otitis and rhinosinisitis in children suffering from these diseases.
Adenoidectomies, no matter the size of the adenoids, improve the symptoms of rhinosinusitis and decrease the risks of recurrent or persistent middle ear effusions or infections in children older than 3 years. Also, in pre-menopausal adult women, an adenoidectomy can lead to a short term increase in breast mass.
In 1999, a presentation at the American Academy of Pediatrics
American Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...
confirmed this concern by finding that adenoidectomy usually controlled symptoms and infections in children with large adenoids; however, if the adenoid was small and CT scan evidence of chronic sinusitis was present, not as many children improved, leading the authors to believe these children would benefit from initial procedures of adenoidectomy and endoscopic sinus surgery.