Superior adenoidectomy in children with palatal abnormalities.

Abstract

When treating a child with a palatal abnormality for otitis media or a nasal obstruction, otolaryngologists often face the question of whether the benefits of adenoidectomy are worth the risk of the development of velopharyngeal insufficiency. Treatment options for these patients include a complete adenoidectomy, a partial adenoidectomy, or no surgical intervention. In this retrospective study, we describe the outcomes of 22 such patients who were treated with a superior adenoidectomy performed with a St. Clair adenoid forceps under indirect vision with a laryngeal mirror. All patients experienced a complete or near-complete resolution of their nasal obstruction, and none developed permanent velopharyngeal insufficiency. Only three patients experienced a recurrence of otitis media. Our experience suggests that superior adenoidectomy is a safe and effective procedure.

Introduction

The role of adenoidectomy has been well defined as a treatment modality for children who have recurrent acute otitis media or persistent chronic otitis media with effusion. [1] The procedure is also effective in relieving persistent nasal obstruction (with or without obstructive sleep apnea) and chronic sinusitis. [1] However, an adenoidectomy performed in a patient with a palatal abnormality-- such as a short soft palate, a bifid uvula, or a submucosal cleft palate--can cause velopharyngeal insufficiency. [2-5] This problem has been recognized for a long time, and otolaryngologists often face a dilemma in trying to decide whether the benefits of adenoidectomy are worth the risks. [6] Many authors recommend forgoing adenoidectomy because of the risk of postoperative hypernasality. [7] When some form of surgical intervention is necessary, many surgeons prefer to perform a partial adenoidectomy, but there is no consensus as to which type of adenoidectomy is best. [6]

One little-used procedure is a superior adenoidectomy performed with an adenotome. This procedure was first described by Birrell [8] in 1966 and later by Shapiro, [9] but since then it has been mentioned only occasionally. [6,10] In this paper, we retrospectively report the outcomes of 22 children with a high risk of velopharyngeal insufficiency who underwent surgery with a modification of the technique described by Birrell. In these cases, a superior adenoidectomy was performed with a St. Clair forceps (figure) rather than with an adenotome.

Patients and methods

We reviewed the records of all adenoidectomies performed by or under the supervision of one pediatric otolaryngologist (MMA) during a 13-month period (Aug. 1, 1994, through Aug. 31, 1995). All procedures were performed at the University Hospital and Medical Center at the State University of New York at Stony Brook. During that time, 164 children had undergone an adenoidectomy, with or without a tonsillectomy. In addition to the information gleaned from presurgical and followup notes in the patients' records, followup Outcomes data were obtained from telephone surveys conducted in April 1996.

In preparation for the surgery, all patients were placed under orotracheal general anesthesia and were fitted with a Davis-Crowe mouth gag. The hard and soft palates were examined by visual inspection and palpation. The adequacy and length of the soft palate were assessed, and the soft palate was considered to be short if its posterior border could not be made to reach the posterior pharyngeal wall when it was manually stretched intraoperatively. At this point, the information learned from this evaluation was combined with the information obtained preoperatively, and the decision was then made to perform either a complete or partial adenoidectomy. A superior adenoidectomy was performed on patients who had a short soft palate, a bifid uvula, a submucosal cleft palate, or preoperative evidence of impaired palatal mobility.

Superior adenoidectomy was performed on 22 patients with a St. Clair adenoid forceps (Karl Storz; Tuttlinger, Germany) under indirect vision with a laryngeal mirror. The open forceps were pressed against the upper portion of the adenoid, high in the nasopharynx. This was done first on the right side and then on the left, until both chonae and the posterior edge of the nasal septum were clearly visible. An oxymetazoline-soaked tonsil sponge was placed in the nasopharynx to promote hemostasis. After the sponge was removed, final hemostasis was achieved with a suction coagulator (Force2, Valleylab; Boulder, Colo.), and blood loss was measured. The nasal cavity and nasopharyax were then irrigated with normal saline administered with a 60-ml bulb syringe. An orogastric tube was passed to empty the stomach.

Followup examinations were conducted at 4 weeks, 6 months, and 1 year after surgery, unless needed sooner.

Results

Between Aug. 1, 1994, and Aug. 31, 1995, 164 patients underwent an adenoidectomy, with or without tonsillectomy, for nasal obstruction, obstructive sleep apnea, and/or chronic or recurrent otitis media. All patients were under the care of the senior author (MMA). Twenty-two of these patients (13%), 11 of each sex, required a superior adenoidectomy. Their ages ranged from 3 to 10 years (mean: 5). The indications for adenoidectomy in general for these 22 children were chronic otitis media with effusion (n=10), recurrent acute otitis media (n=4), and adenoid hypertrophy, mouth breathing, and snoring (n=21). In some patients, the latter group of symptoms was associated with obstructive sleep apnea (n=7), total nasal obstruction (n=2), and recurrent sinusitis (n=1). The indications for superior adenoidectomy were a short soft palate (n=14), bifid uvula (n=4), and questionable palatal mobility (n=4).

The following associated features were noted in the patients who underwent a superior adenoidectomy: two previous myringotomies with tube insertions (n=2), asthma or dust allergy (n=3), heart murmur (n=1), central perforation (n=l), cholesteatoma (n=1), unilateral sensorineural hearing loss (n=1), and cerebral palsy and developmental delay (n=2). In addition, the following associated procedures have been performed: tonsillectomy (n=12), bilateral myringotomy with tubes (n=11), bilateral myringotomy without tubes (n=1), unilateral myringotomy (n=1), frenectomy (n=1), and a microscopic examination of the ear (cholesteatoma) (n=1).

During surgery, the estimated blood loss ranged from 6 to 60 ml (mean: 31). The high end of these estimates represents the cumulative blood loss in patients who required a cautery tonsillectomy. There were no primary or secondary hemorrhages.

Followup

One patient was lost to followup. During the immediate postoperative period, one patient had temporary nasal regurgitation, which resolved without any further treatment; this 10-year-old girl had undergone a tonsillectomy in addition to the superior adenoidectomy for obstructive sleep apnea. She had a short soft palate, but no bifid uvula or submucosal cleft palate.

All of the patients who underwent surgery for adenotonsillar hypertrophy that caused nasal symptoms or obstructive sleep apnea reported a complete or near-complete resolution of symptoms. Two patients who had undergone a myringotomy without tubes experienced recurrence of acute otitis media, although it was less frequent and less severe. Nonetheless, they both experienced a resolution of their obstructive symptoms. Another patient who had received two previous sets of tympanostomy tubes and who was under the care of an allergist required another (fourth) set of tympanostomy tubes 1 year after the superior adenoidectomy.

No patient developed hypernasality or permanent nasal regurgitation of fluids, and none required further adenoid intervention during the following year.

Discussion

The risk of developing vebopharyngeal insufficiency subsequent to an adenoidectomy is well known. Gibb reviewed data on 27,734 children who had undergone tonsil and adenoid removal and found that only 19 had experienced subsequent hypernasality; 18 of them had some degree of a short soft palate, and five also had a bifid uvula. [2]

Calnan defined submucosal cleft palate as the triad of a bifid uvula, notching of the posterior border of the hard palate, and a muscular diastasis of the velum (zona pellucida). [11] Lubit described the prevalence of bifid uvula as 1 in 75. [12] Shprintzen et al performed nasopharyngoscopy on 25 patients with a bifid uvula and found that the musculus uvulae was absent in 19. [7] Of these 19 patients, 11 had diastasis of the velum. The authors concluded that the presence of a bifid uvula raises the possibility that the patient has a submucosal cleft palate.

Mason described the prognostic indicators of velopharyngeal insufficiency following adenoidectomy. [13] These indicators include a submucosal defect of the hard palate, a short or thin velum, anterior dimpling of the velum, midline translucency of the velum, poor velar elevation, and the presence of a bifid uvula. He emphasized the importance of evaluating the point where the soft palate buckles during phonation in relation to the pharynx. The further forward the dimple on the elevated soft palate is, the less the effective length of the velum is. Calnan reported a series of what he called "congenital large pharynx" in patients who were also at increased risk for velopharyngeal insufficiency following adenoidectomy. [3] A list of such prognostic indicators is summarized in table 1. [5]

Lateral adenoidectomy has been performed in an attempt to prevent velopharyngeal insufficiency in patients with an inadequate palate who require an adenoidectomy. [3] However, Masters et al reported that the removal of the lateral portions of the adenoids ("lateral bandectomy") was not effective in the treatment of hearing loss. [14] Anterior partial adenoidectomy has also been suggested by Seid, although no data were mentioned in his report. [6] Seid reported that nasopharyngoscopy was performed immediately prior to surgery. Adenoids were marked with methylene blue or other dyes transnasally with a thin applicator in order to guide the surgeon in the selective removal of lymphoid tissue. Other authors have reported that a "medical adenoidectomy"--i.e., a short, intensive course of steroids--achieved a short-lasting reduction in the size of adenoids. [6] The use of gamma globulin injections to raise the general resistance was reported in the l960s. [15]

Birrell described a modified adenoidectomy technique for patients in whom the competence of the palate was in doubt. [8] He used an adenotome to selectively remove the upper portion of the adenoid. Hemostasis was achieved with packing. Radiographs taken up to a year following surgery showed no evidence of any regrowth of the upper portion of the adenoid. Later, Shapiro described a series of 58 patients who were treated with essentially the same superior adenoidectomy technique, and he reported excellent results, as no patient developed velopharyngeal insufficiency. [9]

We have found that the use of the St. Clair forceps with mirror control to perform a superior adenoidectomy provides for a more precise excision and avoids injury to the torus tubarius. In our experience, the success of superior adenoidectomy in patients with nasal obstruction is evident, as all patients experienced relief of the obstruction. Of the 14 patients who had chronic otitis media with effusion or recurrent acute otitis media, only three experienced a subsequent recurrence of otitis media.

There were no problems with bleeding in any of our patients. Although the conventional wisdom is that an incomplete adenoidectomy is associated with a higher risk of continued bleeding from the adenoid bed, the use of a suction coagulator with mirror control has helped prevent this problem.

Opponents of any form of adenoidectomy for patients with palatal abnormalities sometimes argue that these patients are at risk of developing velopharyngeal insufficiency at puberty. However, the development of velopharyngeal insufficiency at puberty in the absence of a complete adenoidectomy or cleft palate is unusual. [16] Children seem to compensate very well to a slow atrophy of the adenoid, but not as well to the abrupt removal of the entire adenoid. One approach to treating children with palatal abnormalities and obstructive sleep apnea or snoring is summarized in table 2.

Why so many patients of a single otolaryngologist had their palate competence in doubt is an obvious concern. One explanation might be a selective referral pattern. Another factor to consider is that as the success of the procedure became clear, the surgeon (MMA) concluded that it was better to err on the side of conservatism and retain some adenoid tissue inferiorly when there was any question of palatal competence. This approach takes into consideration the possibility that a revision procedure might he needed in the future to deal with the regrowth of the inferior adenoid tissue.

In conclusion, superior adenoidectomy with a St. Clair forceps appears to be a safe and effective procedure. It should be considered when there is any question about palatal competence. Prospective studies that reported objective pre- and postoperative evaluations of velopharyngeal insufficiency would be helpful in further assessing the usefulness of this procedure in selected cases.

From the Division of Otolaryngology--Head and Neck Surgery, Department of Surgery, State University of New York at Stony Brook.

References

(1.) Gates GA. Sizing up the adenoid. Arch Otolaryngol Head Neck Surg 1996;122:239-40.

(2.) Gibb AG. Unusual complications of tonsil and adenoid removal. J Laryngol Otol l969;83:l159-74.

(3.) Calnan JS. Congenital large pharynx: A new syndrome with a report on 41 personal cases. Br J Plast Surg 1971;24:263-71.

(4.) Witzel MA, Rich RH, Margar-Bacal F, Cox C. Velopharyngeal insufficiency after adenoidectomy: An 8-year review. Int J Pediatr Otorhinolaryngol 1986;11:15-20.

(5.) Finkelstein Y, Berger G, Nachmani A, Ophir D. The functional role of the adenoids in speech. Int J Pediatr Otorhinolaryngol 1996;34:61-74.

(6.) Seid AB. Velopharyngeal insufficiency versus adenoidectomy for obstructive sleep apnea: A quandary. Cleft Palate J 1990;27:200-2.

(7.) Shprintzen RJ, Schwartz RH, Daniller A, Hoch L. Morphologic significance of bifid uvula. Pediatrics 1985;75:553-61.

(8.) Birrell JF. Palatal disproportion in children. J Laryngol Otol 1966;80:706-17.

(9.) Shapiro RS. Partial adenoidectomy. Laryngoscope 1982:92:135-9.

(10.) Mann EA, Sidman JD. Results of cleft palate repair with the double-reverse Z-plasty performed by residents. Otolaryngol Head Neck Surg 1994;1ll:76-80.

(11.) Calnan J. Investigation of nasality (nasal escape) in speech. Speech 1957;21:59-74.

(12.) Lubit EC. Before adenoidectomy--Stop! Look! and Listen! NY State 3 Med 1967;67:681-5.

(13.) Mason RM. Preventing speech disorders following adenoidectomy by preoperative examination. Clin Pediatr(Phila) 1973;12:405-14.

(14.) Masters FW, Bingham HG, Robinson DW. The prevention and treatment of hearing loss in the cleft palate child. Plast Reconstr Surg 1960;25:503-9.

(15.) Gray L. The T's and A's problem--assessment and reassessment. J Laryngol Otol 1977;91:11-32.

(16.) Shapiro RS. Velopharyngeal insufficiency starting at puberty without adenoidectomy. Int J Pediatr Otorhinolaryngol 1980;2:255-60.

Risk factors for velopharyngeal insufficiency following adenoidectomy

Family history of cleft palate and lip

Congenital malformations, particularly cardiovascular

Known craniomaxillofacial malformations, including a malformed auricle or other signs of Goldenhar's sequence

Infant feeding problems, primarily a weak sucking reflex, nasal regurgitation, or "slowness to feed"

Poor fine-motor coordination

Gross motor problems

Delayed speech development

Learning disabilities

Hyper- or mixed nasality or misarticulation

Intraoral findings such as bifid uvula, muscular diastasis of the soft palate (zona pellucida), notching of the hard palate, or abnormal palatal dimpling

Narrow palpebral fissures, flattening of zygomatic bones

Neurologic disorders such as Arnold-Chiari malformation, myotonic dystrophy, pseudobulbar palsy, pharyngeal paresis, myasthenia gravis, and neurofibromatosis 

Approach to children with palatal abnormalities and obstructive sleep apnea or snoring

Exclude or correct turbinate enlargements, chronic rhinosinusitis, and lingual hypertrophy.

Exclude or correct neurologic disorders.

Consider a tonsillectomy.

Consider a modified uvulopalatopharyngoplasty.

Consider continuous positive airway pressure.

Prescribe a "medical adenoidectomy."

Perform an anterior partial adenoidectomy, a superior adenoidectomy, or a lateral adenoidectomy.