8 Surgery of the Epipharynx Curettage of the lymphadenoid tissue of the nasopharynx. Significant hyperplasia of the pharyngeal tonsil associated with: General anesthesia with orotracheal intubation or larynx mask. Beckmann ring knife or appropriate instrument of various sizes, Jurasch forceps, curved suction tube with spherical tip, conchotome (triangular jaw), mouth gag (e. g., McIvor gag), nasolaryngoscope or angled scope, bipolar diathermy, suction cautery. – Usually due to retained pharyngeal tonsil tissue. – In rare cases due to an unrecognized coagulopathy. – In extremely rare cases due to injury to ectopic branches from the external carotid artery region. Kinking of the internal carotid artery is regarded as a most extreme rarity. Severe arterial hemorrhage initially requires firm packing, followed by revision of the carotid sheath from an external approach. – Residual adenoid tissue, unrecognized coagulopathy: recurette, clotting profile, consider blood component replacement therapy, exclude aspiration.
Adenoidectomy
Surgical Principle
Indications
Nasal airway obstruction, mouth breathing, snoring, obstructive sleep apnea syndrome.
Recurrent sinusitis, chronic purulent rhinitis, nasopharyngitis.
Recurrent middle ear effusion (otitis media, glue ear), serous or mucoid otitis media.
Recurrent laryngitis or tracheobronchitis.
Contraindications
Overt, operated or submucous cleft palate.
Hypernasal speech (rhinolalia aperta) (phoniatric assessment).
Bleeding disorder or coagulopathy.
An urgent indication in children only before their second year of life.
Suspected juvenile nasopharyngeal fibroma.
Specific Points Regarding Informed Consent
Risk of postoperative bleeding, risk of aspiration with subsequent extremely rare risk of hypoxia.
Damage to teeth.
Transient, in exceptional cases permanent, hypernasal voice.
Nasopharyngeal stenosis secondary to scar formation.
Scar formation at the orifice of the eustachian tube with subsequent recurrent otitis, conductive hearing loss.
Cervical lymphadenopathy or prevertebral fasciitis with subsequent torticollis.
Risk of recurrence.
Revision surgery.
Outpatient surgery: specific instructions regarding postoperative behavior and observation.
Operative Planning
Nasopharyngoscopy/endoscopy. Identification of indirect signs such as serous otitis media, marked nuchal lymph-adenitis.
Blood count and clotting profile.
Anesthesia
Special Instruments
Surgical Technique
Positioning: head-down position achieved by lowering the head rest or placing padding beneath the shoulders; reclination (Fig. 8.1).
Introduction of the McIvor blade: A closed blade corresponding in size to the anatomy of the mouth is introduced, placed over the oral intubation tube (which is placed in the midline), and then opened after being supported on the canines.
The pharynx is inspected using the nasolaryngoscope or angled scope.
A ring knife, appropriate in size to the patient’s age, is passed beneath the soft palate and up to the roof of the pharynx, behind the margin of the vomer.
The knife is then drawn downward with mild pressure, keeping the blade straight and strictly in the midline. An approach that is controlled and not too abrupt will avoid injury to the arch of the atlas, the prevertebral fascia, or the mucous membrane of the oropharynx (Fig. 8.2).
The pharyngeal recesses are curetted after removal of the adenoids. The ring knife is again held in the midline, advanced parallel with the blade straight into the pharyngeal recess and, while maintaining light contact with the tissue, is then drawn back again in a strictly craniocaudal direction (Fig. 8.3).
Remaining remnants of mucosa and residual adenoid tissue over the lower curetted margin are removed with the conchotome (Fig. 8.4).
The nasopharynx is checked with the laryngoscope/endo-scope or by palpation with a finger or ring knife. Residual adenoid tissue is re-curetted or removed under direct vision with the Jurasch forceps.
Hemostasis is achieved by inserting a swab, attached to a thread and possibly soaked with nose drops, into the nasopharynx for 3 minutes; it is imperative to confirm its removal (risk of bolus obstruction). Any bleeding that still continues is then directly coagulated with a bipolar diathermy or by suction cautery under endoscopic vision after drawing the soft palate forward.
The pharynx is suctioned before extubation.
Rules, Tips, and Tricks
All adenoidal tissue must be removed, otherwise there is the danger of postoperative bleeding and the risk of recurrence.
Check the nasopharynx for any retained swabs. If more than one swab is used, always insert the swab attached to a thread first, to be subsequently removed last. Do a swab count.
Residual tissue may also be removed transnasally with forceps under endoscopic guidance, or by endoscopy via the nose, removing the tissue transorally.
Risks and Complications
Persistent bleeding during the operation:
Postoperative bleeding:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Ento Key
Fastest Otolaryngology & Ophthalmology Insight Engine
