Pharyngeal Tonsillectomy (Adenotomy)

Adenotomy (synonyms: pharyngeal tonsillectomy, removal of adenoids) is a surgical procedure from the field of otolaryngology and is used to remove so-called adenoid growths (adenoid hyperplasia; hyperplasia of the tonsilla pharyngea; synonyms: tonsilla pharyngealis, tonsilla pharyngica, adenoid vegetations or – in common parlance – polyps). These are hyperplastic (greatly enlarged) pharyngeal tonsils (tonsilla pharyngea). Adenoids are also popularly known as polyps and usually occur in childhood. The cause of hyperplasia of the pharyngeal tonsil is a hereditary disposition, but possible factors such as recurrent (recurring) infections, diet or hormonal influences are discussed or suspected. The consequences of adenoids result from their anatomical location in the pharynx: Young patients are obstructed in their nasal breathing, speak with a nasal voice and snore during sleep. Another symptom is the so-called facies adenoidea: A typical condition that is noticeable by mouth breathing or a constantly open mouth. Further impairments caused by the adenoids become apparent in the patients’ everyday life. Declining school performance is the result of poor concentration and sleep disturbances, patients tire quickly and often show a reluctance to eat. A number of secondary diseases may develop:

  • Chronic rhinitis – chronic rhinitis.
  • Chronic laryngitis – chronic inflammation of the larynx.
  • Chronic tracheitis – chronic inflammation of the trachea.
  • Chronic bronchitis – chronic inflammation of the bronchi.
  • Tubal catarrh with tympanic effusion (synonym: seromucotympanum; accumulation of fluid in the middle ear (tympanum)) – inflammation of the tubes (connection between the ear and throat) with tympanic effusion.

Diagnosis of the diseases is made by X-rays, posterior rhinoscopy (nasal endoscopy, which also allows inspection of the pharynx) or transnasal endoscopy (pharyngeal endoscopy). There are two strategies for the treatment of adenoid hyperplasia: watchful waiting and adenotomy. The indications for adenotomy are listed below.

Indications (areas of application)

  • Hyperplasia of the pharyngeal tonsils (adenoid hyperplasia) leading to chronic obstruction of nasal breathing
  • Chronic recurrent (frequently recurring) inflammation of the pharyngeal tonsils.
  • Chronic otitis media (inflammation of the middle ear)/recurrent (recurrent) acute otitis media in hyperplasia of the pharyngeal tonsils.
  • Chronic bronchitis (inflammation of the bronchi) in hyperplasia of the adenoids.
  • Chronic rhinitis (rhinitis) in hyperplasia of the adenoids.
  • Chronic sinusitis (sinusitis)/recurrent rhinosinusitis (simultaneous inflammation of the nasal mucosa (“rhinitis”) and the mucosa of the paranasal sinuses (“sinusitis“)) in hyperplasia of the adenoids.
  • Obstructive sleep apnea (OSA) – sleep-disordered breathing (SBAS) with pauses in breathing caused by obstruction of the upper airway.
  • Recurrent (recurrent) upper respiratory tract infections in hyperplasia of the pharyngeal tonsils.
  • Tubal ventilation disorder (ventilation disorder of the middle ear) with mucotympanum (tympanic effusion with mucous (= viscous-mucous) fluid).

Contraindications

  • Coagulation and bleeding disorders
  • Cleft lip and palate
  • Rhinolalia aperta – nasal vocal sound produced by an incomplete closure of the nasal cavity from the mouth
  • Intervention in children before the age of 2 (except for urgent indication).
  • Suspicion of juvenile nasopharyngeal fibroma – hereditary disease with connective tissue proliferation in the nasopharynx.

Before surgery

After a detailed medical history discussion with the patient and detailed explanation of the procedure, the physical examination is performed. The nasopharynx is again mirrored or examined with an endoscope.In addition, a blood count and the patient’s coagulation status (“activated partial thromboplastin time,” aPTT; “international normalized ratio,” INR)) are obtained; alternatively, a standardized questionnaire is used preoperatively to assess a possible coagulation disorder (if this indicates no abnormalities, determination of coagulation parameters is unnecessary).Anticoagulants such as acetylsalicylic acid (ASA) should not be taken or should be discontinued seven to 10 days before surgery.

The surgical procedure

The surgery takes place under general anesthesia, and the patient is usually intubated (placement of a tube – tubing – that secures airflow) or given a laryngeal mask (the laryngeal mask is placed over the larynx and also secures airflow during anesthesia). During the operation, the patient is in the supine position with the head hanging down. The surgical area is covered sterilely and the surgeon inserts a Kilner-Doughty mouth gag (this instrument holds the mouth open so the surgeon can access the throat). The tongue is pushed down and fixed with the tube. Now the adenoids can be removed under constant endoscopic visual control (“mirroring”) with the help of a ring knife. For this purpose, the adenoids are cut off at their base while the blood is aspirated. Bleeding can usually be stopped with a swab, otherwise selective sloughing can be performed by coagulation. If there is concomitant tympanic effusion, a paracentesis (tympanic membrane incision), with insertion of a tympanic ventilation tube if necessary, can be performed during the same procedure.

After surgery

After surgery, the patient should avoid food for about 4 hours. Tea and rusks can then be offered, and normal eating is possible again the day after surgery.

Possible complications

  • Postoperative bleeding (0.2-0.8% of cases).
  • Wound infection
  • Scarring with narrowing of the pharynx
  • Scarring in the area of the auditory tract with otitis (ear infections) and hearing loss.
  • Injury to the tubal cartilage with subsequent tubal ventilation disorder (ventilation disorder of the middle ear).
  • Recurrences (recurrent proliferation) of adenoids.
  • Difficulty swallowing
  • Velopharyngeal insufficiency, open nasal (Rhinolalia aperta) (temporary or even permanent).
  • Grisel syndrome (torticollis atlantoepistrophealis) – subluxation of the cervical spine in the atlantoaxial joint due to a pain-induced gentle posture based on inflammation in the ENT area.
  • Tooth damage

Other notes

  • Adenotonsillectomy
    • During adenotonsillectomy (adenotomy + tonsillectomy (removal of the palatine tonsils); T + A), obese children gain increased weight. Causes are probably children who have been cured of obstructive sleep apnea (OSA) by surgery, are less hyperactive during the day, ie, move less, and in addition, their nocturnal work of breathing is reduced, which reduces calorie consumption during sleep.
    • Children who had a tonsillotomy (removal of the palate tonsil) or adenotomy (removal of the pharyngeal tonsil) before the age of 10 were more likely to develop a range of infections (2-3 times more likely to develop respiratory diseases) and allergic diseases later in life.
    • Adenotonsillectomy improved asthma in asthmatic children with sleep disorders (increase in C-ACT score from 21.86 to 25.15 (p < 0.001). In contrast, the control group showed only a nonsignificant improvement from 22.42 to 23.59).