Accepted Manuscript Title: Objective assessment of endoscopy assisted adenoidectomy Author: Ismail Elnashar Mohammad waheed El-Anwar Waleed Mohammad Basha Mohamed AlShawadfi PII: DOI: Reference:

S0165-5876(14)00243-2 http://dx.doi.org/doi:10.1016/j.ijporl.2014.04.031 PEDOT 7099

To appear in:

International Journal of Pediatric Otorhinolaryngology

Received date: Revised date: Accepted date:

17-2-2014 10-4-2014 16-4-2014

Please cite this article as: Ismail Elnashar, Mohammad waheed El-Anwar, Waleed Mohammad Basha, Mohamed AlShawadfi, Objective assessment of endoscopy assisted adenoidectomy, International Journal of Pediatric Otorhinolaryngology http://dx.doi.org/10.1016/j.ijporl.2014.04.031 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Objective assessment of endoscopy assisted adenoidectomy By Ismail Elnashar *, Mohammad waheed El-Anwar *, Waleed Mohammad Basha*, Mohamed Ahmad Alshawadfy **

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Otorhinolaryngology-Head and Neck Surgery Department, Faculty of

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Medicine, Zagazig University, EgyptOtorhinolaryngology-Head and

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Neck Surgery Department, Faculty of Medicine, Zagazig University, Egypt.

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Corresponding author : Otorhinolaryngology, Head and Neck Surgery

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Department, Faculty of Medicine, Zagazig University, Egypt.

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ABSTRACT

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Tel: 00201004695197; Fax: 0020552307830, Email: [email protected]

Objectives: To objectively assess the effectiveness of endoscopy assisted adenoidectomy utilizing adenoid tissue volume measurement and to set some parameters for which patients are more legible to this procedure. Methods: Forty three patients for whom adenoidectomy was conventionally done using adenoid curettes. Surgeon's satisfaction for adenoid removal after curettage and digital palpation was reported. The volume of removed adenoidal tissue was measured. The remaining adenoid tissue, if any, was removed transnasally guided by endoscope. Residual adenoid volume was also was measured. The data was tabulated and statistically analyzed. Results: The volume of adenoid removed by curettage ranged from 1 to 3.6 ml with a mean of 2.45 ml. The volume of residual adenoid removed by endoscopy after

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curettage ranged from 0 to 2.9 ml (mean: 0.67± 0.58 ml). The volume of residual adenoid after blind curettage was found to have statistically significant relation to older age of patients, preoperative larger adenoid by X-ray and Surgeon's dissatisfaction about the completeness of removal after curettage.

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Conclusion: Conventional curettage adenoidectomy misses a substantial volume of adenoid tissue. Endoscopy-assisted adenoidectomy is significantly recommended in

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children age > 10 years, dissatisfied surgeon after curettage and palpation, and grade 3

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adenoid enlargement on X- ray.

Keywords: adenoidectomy, endoscopy, curette, adenoid volume.

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INTRODUCTION

Whether performed alone or combined with tonsillectomy, adenoidectomy is one of

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the most common surgical operations in pediatric otolaryngological practice (1). Due to the large number of adenoidectomies performed, surgeons must lay particular

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attention to the safety, accuracy and outcomes when choosing among different

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surgical techniques. Since it was first described in 1885 (2), curette adenoidectomy with pack hemostasis is considered the most commonly used surgical technique for adenoidectomy (1). Despite the trials of indirect visualization with laryngeal mirrors, the conventional technique is more or less a blind procedure. Both Cannon et al (3) and Havas et al (4) have drawn attention to the high percentage of residual tissue remaining after traditional adenoidectomy with curette (4), especially in the choanal and tubaric regions (5).

Since 1992, a number of Authors have described visualization of the operating field, during surgery, with trans-nasal (6) or trans-oral endoscope (7). Those Authors employed curette, suction-coagulator (5), forceps (8) and transnasal or trans-oral microdebrider (9, 4) as surgical tools for the removal of the adenoids. The use of the

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rigid endoscope has its advantages. It allows good visualization ensuring complete removal of adenoid tissue situated even high up in nasopharynx and intranasally without damaging surrounding structures. When used transnasally there is no need to extend the neck especially in patients with instability of the cervical spine (4). If

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partial adenoidectomy is appropriate, it is also possible to perform very selective removal of the adenoid tissue (1).

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Despite the many advantages described by many authors for the use of the endoscopic

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technique, there are only few studies which objectively proved the effectiveness of this technique over the traditional one. These studies also, didn’t provide sufficient

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data to abandon the traditional technique and make the endoscopic technique the standard of care.

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In this work, the authors tried to objectively prove the effectiveness of the endoscopic technique, by measuring the volume of residual adenoid tissue removed through

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endoscopy after finishing the traditional curettage and comparing this with the volume

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of the whole adenoidal tissue removed; and in this way trying to set some parameters for which cases are more likely to require same setting endoscopic intervention after traditional cold curettage. Patients and methods

The study included 43 patients for whom endoscopy assisted adenoidectomy was performed in the period from November 2010 to November 2013. This study was approved by the Ethics Review Committee at Zagazig University Hospitals and informed written consent was obtained from the parents of the enrolled subjects. All patients were subjected to full history taking, clinical examination, laboratory testing and radiological examination including plain X-ray nasopharynx and/or CT. The radiological findings were recorded then interpreted based on Cohen method (1). All

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patients had Medium (grade 2) to Large (grade 3) adenoids. Patients with small adenoid enlargement were not included in the study. Children with cleft palate were also excluded. The surgeries were performed by well experienced surgeons who performed at least five hundred adenotosillectomies and works as consultant at

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Zagazig University hospitals (tertiary care hospital). Topical nasal decongestion (Oxymetazoline spray) was used preoperatively. All surgeries were done under

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general anaethesia with oral endotracheal intubation. Adenoidectomy was done using

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sharp adenoid curettes in the conventional way and the surgeon was allowed to palpate the adenoid bed and repeat the curettage to assure complete removal.

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Surgeon's satisfaction for complete adenoid removal after curettage and digital palpation was reported as satisfied (Surgeon could not feel any residual adenoid tissue

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by digital palpation of nasopharynx and posterior choanae) or dissatisfied (Surgeon felt residual adenoid tissue but could not be reached and excised by curettage).

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The volume of the excised adenoid was measured by putting it in a graded measuring

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tube containing 5 ml saline after removal of all blood clots and any moisture. The increase in saline volume above 5 ml was calculated and represented the removed adenoid tissue volume. This measure was revised independently by two of the authors at least. Similar method was used by Yilmaz et al, 2008 (10) but we preferred to use a graded measuring tube instead of the syringe to allow placing tube vertical to read and measure it accurately and avoid the possibility of fluid escape around the finger closing the syringe tip.

The mouth gag was disarticulated and the patient was placed in endoscopic sinus surgery position. The remaining adenoid tissue, if any, was removed transnasally under endoscopic guidance using straight and curved forceps until the adenoid was

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removed completely (figures 1, 2). If there was any bleeding, suction cautery was used to stop it. The part removed through the endoscope was put in another measuring tube and its volume was separately measured. The results of the study were statistically analyzed

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using a t test (table 2, 3). Results

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The study included 28 (65.1%) males and 15 (34.9%) females. Their ages ranged

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from 1 year and 6 months to 17 years with a mean age of 8 years and 3 months. The surgery was performed alone in 23 (53.5%) patients including 4 recurrent (9.3%)

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patients and as part of other surgery in 20 (46.5%) patients including 9 with tonsillectomy, 8 with ventilation tube insertion and 3 with FESS. The volume of

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adenoid removed by curettage ranged from 1 to 3.6 ml with a mean (± SD) of 2.46 ml. (± 0.62). The volume of residual adenoid removed by endoscopy after curettage

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ranged from 0 to 2.9 ml with a mean (± SD) of 0.67 (± 0.58) ml (Table 1). The mean

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percent of part endoscopically removed was 21.5% of total adenoid size. Preoperative radiology showed Medium (grade 2) adenoid in 13 (30.2%) and Large (grade 3) in 30 (69.8%) cases. For patients with grade 2 adenoid enlargement, the volume of adenoid removed by endoscopy after curettage ranged from 0 to 1.1 ml (mean ± SD was 0.42 ± 0.25 ml). For Large (grade 3) adenoid, the volume of adenoid removed by endoscopy after curettage ranged from 0 to 2.9 ml (mean ± SD was 0.78 ± 0.66 ml) (Table 2). For the 22 patients (51.2%) in whom the surgeon was satisfied after adenoid removal by curettage, the size of adenoid removed by endoscopy after curettage ranged from 0 to 0.6 ml (mean ± SD was 0.33 ± 0.16 ml). For the 21 (48.8%) unsatisfactory adenoid removal by curettage, the volume of adenoid removed by endoscopy after curettage ranged from 0.3 to 2.9 ml (mean ± SD was 1 ± 0.67 ml)

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(Table 2). The mean percent of part endoscopically removed was 21.5% of total adenoid size. According to age, patients aged 10 years or more had more residual adenoid volume after curettage that was detected and removed endoscopically than children aged less than 10 years and the difference was statistically significant (t;

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4.2066 and P value; < 0.0001) (Table 3). Discussion

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Adenoidectomy with or without tonsillectomy is a common surgical procedure in

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children. A considerably high correlation was found between the adenoid size and the total symptom scores. Because the size of adenoid tissue has high effect on symptoms

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of nasal obstruction (8), complete removal is the main target of adenoidectomy. Although various techniques had been described for adenoidectomy, the ‘‘blind

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curette technique’’ is still widely performed (9). Blind curettage cannot clear the

cause of recurrence (11, 12).

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adenoidal tissue within the posterior choanae, which is sometimes the most important

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Some researchers (3, 13, 14), used endoscopic grading to assess residual adenoid tissue but this was done with subjective categorization of the site of the residual or the difference between the two choanae irrespective to the total volume of the residual in the nasopharynx. Therefore this grading doesn’t reflect the total airway compromise that could be better assessed with residual volume assessment. In this study, volume assessment was chosen to objectively and accurately evaluate all the residual adenoid tissue after conventional curettage. Endoscopic transnasal forceps was used in this study to enable collecting the tissues for measuring their volumes. Endoscopic transnasal forceps removal has some disadvantages as prolonged operative time, more bleeding than microdebrider or electrocautery, and uncomfortable work in the narrower side of septal deviation if present.

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In our study, residual adenoidal tissue after curettage was found in 95.45% of cases. This high percent of residual can be explained because we reported all residual tissue whether obstructing or not, and because we used intra-operative endoscopic visualization. This is near to Kamel and Abdel Fattah (11) who reported 92% adenoid

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residual after curette adenoidectomy. In contrast, a lower rate of residual of 20.2% was reported by Ark et al (15) and Havas and Lowinger (39%) (4). This can be

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explained by their use of indirect mirror visualization as the method of assessment in

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the former and the reporting of only obstructing residual in the latter. Bross-Soriano et al used a laryngeal mirror during curettage which decreased the incidence of residual

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but was not enough and a residual adenoid was left in 71.3% of the cases (13). Dissatisfaction with the conventional technique has prompted the use of other

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methods of visualization and removal, including endoscopic powered-shaver (4). coblation (16) or electrocautery adenoidectomy (5). In spite of this, curette

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adenoidectomy was not abandoned and still, it’s the most widely performed technique

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(1) and post operative symptom improvement occurs in the majority of patients. The main disadvantage of endoscopic technique compared with traditional cold curettage is the need to have a complete set-up for pediatric endoscopy in the operating theatre that would increase the cost and time of surgery. In addition, a specific learning curve in pediatric endoscopy is required (16). That is why in this study, we tried to find out nonendoscopic indications (dependable parameters) to stop adenoidectomy surgery at conventional curettage adenoidectomy or to proceed with endoscopic removal of residual and we tried to choose predictors easy and available to perform. We used surgeon satisfaction after digital palpation as an indicator of completeness of removal and this was compared to the endoscopic findings and the volume of the

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residual adenoidal tissue. Our results insure that palpation provided an accurate indicator of the volume of the residual adenoidal tissues excised by endoscopy. Moreover in the cases where the surgeon was satisfied by palpation after curettage, the volume of residual adenoid was not more than 0.6 ml. These data were evident in

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the study of Yilmaze et al (10) who concluded that the use of indirect mirror visualization is not accurate as palpation. However, Ark et al (15) concluded that

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digital palpation is not a dependable technique for a complete adenoidectomy. In their

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study, they detected a residual in 20.2 % of cases but they did not clarify criteria for the surgeon, volume of the residual and whether it was obstructing or not.

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In the present study, the volume of residual adenoid after blind curettage was found to have statistically highly significant relation to older age of children (> 10 years) and

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Surgeon's dissatisfaction, by digital palpation, after adenoid curettage and was significantly related to preoperative larger adenoid by X-ray (grade 3).

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Our results agree with Gürpınar et al (17) who found a significant correlation between

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the tissue volume extracted during adenoidectomy and lateral radiographs. But our results disagree with Bross-Soriano et al (13), who concluded that it is imperative to use endoscopic revision in each case. We think that there should be some indicators for which patients are more legible to completion endoscopic adenoidectomy. We observed that curettage method is sufficient to remove the main piece of the adenoids in younger children. In contrast to older children, the adenoid tissue is removed in multiple small pieces in the classic blind curette adenoidectomy and there is more chance for leaving a residual. This was evident in our study as we found more adenoid residuals in older children. It is objectively clear from the results of our study that with increased age of children at time of surgery (10 years or more) and with larger size of adenoid by preoperative

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X- ray, more residual adenoid volume was statistically found as more adenoid tissue reaches areas of nasopharynx and/or choanae that are difficult to be reached and blindly curetted by curette; and even difficult to be blindly palpated by experienced surgeon. So these situations need visualization of the adenoid bed and subsequent

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removal of any residual adenoid under vision to improve the accuracy of adenoidectomy.

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We recommend using endoscopy to allow visualization of the nasopharynx for

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complete adenoid removal as possible especially in age > 10 years, unsatisfactory surgeon after curettage and palpation, and grade 3 adenoid enlargement on X- ray.

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Still the effect of different residual adenoid tissue volume on symptoms and adenoid

Conclusion

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regrowth need to be studied.

Conventional curettage adenoidectomy misses a substantial amount of adenoid tissue.

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Rigid endoscopy-assisted adenoidectomy improves this result by enabling localization

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and removal of any residual adenoid tissue. Endoscopy-assisted adenoidectomy is especially recommended in age > 10 years, dissatisfied surgeon after curettage and digital palpation, and grade 3 adenoid enlargement on X- ray. References

1. Costantini F, Salamanca F, Amaina T, Zibor F. Videoendoscopic adenoidectomy with microdebrider. ACTA otorhinolaryngologica italica I, 2008;28:26-29 2. Thornval A, Wilhelm Meyer and the adenoids. Arch Otolaryngol Head Neck Surg. 1969; 90:383-85. 3. Cannon CR, Replogle WH, Schenk MP. Endoscopic-assisted adenoidectomy. Otolaryngol Head Neck Surg 1999; 121:740-4.

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4. Havas T, Lowinger D. Obstructive adenoid tissue: an indication for poweredshaver adenoidectomy. Arch Otolaryngol Head Neck Surg 2002; 128:789-91. 5. Owens D, Jaramillo M, Saunders M. Suction diathermy adenoid ablation. J Laryngol Otol 2005; 119:34-5.

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6. Shin JJ, Hartnick CJ. Pediatric endoscopic transnasal adenoid ablation. Ann Otol Rhinol Laryngol 2003; 112:511-4.

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7. Cohen D, Konak S. The evaluation of radiographs of the nasophaeynx. Clin

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otolaryngology 1985; 1073-8.

8. Yilmaz MD, Kahveci OK, Okur E, Yucedag. The effect of the adenoid of

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hypertrophy rate on upper airway obstruction symptoms. KBB-Forum 2011; 10(4): 74-79.

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9. Ezzat WF. Role of endoscopic nasal examination in reduction of nasopharyngeal adenoid recurrence rates. Int J Pediatr Otol. 2010; 4:404-40.

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10. Yilmaz I, Caylaki F, Yilmazer C, Sener M, Ozluoglu LM. Correlation of

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diagnostic systems with adenoidal tissue volume: a blind prospective study. Int J Pediatr Otorhinolaryngol. 2008; 72(8):1235-40. 11. Kamel RH, Abdel Fattah AF. Choanal adenoid after conventional curettage adenoidectomy. PAJR 2013; 3(1): 5-8.

12. Saxby AJ, Chappel CA. Residual adenoid tissue post-curettage: role of nasopharyngoscopy in adenoidectomy. ANZ J Surg. 2009; 79(11): 809-11. 13.

Bross-Soriano

D,

Schimelmitz-Idi

J,

Arrieta-Gomez

JR.

Endoscopic

adenoidectomy; use or abuse of technology? Cirugia y cirujanos. 2004; 72:1-19. 14. Cassano P, Gelardi M, Cassano M, Fiorella ML, Fiorella R. Adenoid tissue rhinopharyngeal obstruction grading based on fiberendoscopic findings: a novel

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approach to therapeutic management. Int J Pediatr Otorhinolaryngol. 2003; 67(12):1303-9. 15. Ark N, Kurtaran H, Ugur KS, Yilmaz T, Ozboduroglu AA, Mutlu C. Comparison of adenoidectomy methods: examining with digital palpation vs. visualizing the

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placement of the curette. Int J Pediatr Otorhinolaryngol. 2010; 74(6):649-51. 16. Busnco LD, Angelone AM, Mattei A, Ventura L, Lauriello M. Paediatric

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adenoidectomy: endoscopic coblation technique compared to cold curettage. Acta

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Otorhinolaryngol Ital. 2012; 32(2): 124–129.

17. Gürpınar B, Güngör A, Cıncık H, Poyrazoğlu E, Candan H. Comparison of

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radiological findings and clinical data in nasal obstruction due to adenoid hypertrophy

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in children Gulhane Medical Journal 2003;45:10-13.

Figure 1 Intraoperative endoscopic view of right nasal cavity of with completely

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obstructing residual adenoid tissue after curettage (before endoscopic removal).

Figure 2 (A) Intraoperative endoscopic view of left nasal cavity with partially obstructing residual adenoid tissue after curettage. (B) Intraoperative endoscopic view of the same patient after endoscopic removal of the residual adenoidal tissue.

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Table 1: The volume of adenoid removed by conventional adenoidectomy (curettage)

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and endoscopy after curettage.

Range (ml)

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Volume of adenoid

1 to 3.6 0 to 2.9

Percent of total adenoid size

2.45

78.5%

0.67

21.5%

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The volume of adenoid removed by conventional adenoidectomy (curettage) The volume of adenoid removed by endoscopy after curettage

Mean (ml)

Table 2: statistical analysis of the volume of residual adenoid removed by endoscopy after curettage in relation to preoperative adenoid size by X-ray and surgeon satisfaction after curettage.

Volume of residual adenoid removed by endoscopy after curettage 13 (30.2%) large (grade 3) adenoid 30 (69.8%) medium (grade 2) adenoid

Range

Mean

SD

T value

P value

0 to 2.9 ml 0 to 1.1 ml

0.78

0.66 ml 0.25 ml

2.0477

0.0474 (statistically significant)

0.42 ml

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0.3 to 2.9 ml

1 ml

0.67 ml

0 to 0.6 ml

0.33 ml

0.16 ml

5.1414

less than 0.0001 (extremely statistically significant)

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21 (48.8%) unsatisfactory adenoid removed by curettage 22 (51.2%) satisfactory adenoid removed by curettage

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Table 3: statistical analysis of the volume of residual adenoid removed by endoscopy

Mean

0 to 1.2 ml 0.3 to 2.9 ml

0.448 0.279 4.2066 ml ml 1.113 0.738 ml ml

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Range

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Volume of residual adenoid removed by endoscopy after curettage 28 (65.1%) children aged less than 10 years 15 (34.9%)Patient aged 10 years or more

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after curettage in relation to age of patients at time of surgery.

SD

T value

P value

0.0001 (extremely statistically significant)

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Objective assessment of endoscopy assisted adenoidectomy.

To objectively assess the effectiveness of endoscopy assisted adenoidectomy utilizing adenoid tissue volume measurement and to set some parameters for...
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