Adenoid
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Transcript of Adenoid
surgical technique
Powered Partial AdenoidectomyUsing the RADenoid® Bladepresented by L. Nicole Murray, MDand J. Lindhe Guarisco, MD
RADenoid® Bladefrom Xomed
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Powered Partial Adenoidectomy
Surgical technique presented by
L. Nicole Murray, MD and
J. Lindhe Guarisco, MD
Nota Bene: The technique description herein and the use of instructions for the related procedures are made
available by Xomed Surgical Products, Inc. to the health care professional to illustrate the author�s suggested
treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in
the health care professional�s judgment, addresses the needs of the individual patient.
1
PhilosophyThe powered microdebrider has become widely utilized in the practice of
otolaryngology due to its efficiency and safety in functional endoscopic sinus
surgery. Historically, the tool has undergone an evolution from its original
inception by Jack Urban as a rotating dissector for acoustic neuroma removal,
to a small joint arthroplasty tool common in orthopedic surgery, to its current
position in endonasal surgery1. Expanded uses in rhinologic surgery include
removal of both benign and malignant tumors, choanal atresia repair and
adenoidectomy2. The microdebrider consists of an outer windowed sheath
surrounding an inner rotating hollow blade (or bur) which is connected to
standard in-line continuous suction. The window is directed by the surgeon
toward the desired tissue which will be drawn in by the vacuum, and the
rotating blade then shaves the tissue. Specimens may be collected for patho-
logic evaluation by the insertion of a filter sock in the suction canister. The
rising popularity of the microdebrider is in large part due to the ability to
precisely remove desired tissue under direct visualization while leaving adjacent
important structures undisturbed. The importance of precise operative control
is well recognized in the arena of endoscopic sinus surgery, where vital orbital
and intracranial structures must be preserved. Complications of adenoidec-
tomy are less common and less life-threatening than those of FESS, however,
the morbidity of velopharyngeal insufficiency, nasopharyngeal stenosis or
eustachian tube orifice stenosis after adenoidectomy is not to be underesti-
mated. Iatrogenic injury to the velopharyngeal sphincter or to the eustachian
tube orifice is notoriously difficult to repair, and thus is best prevented rather
than treated. In his appraisal of the microdebrider�s utility in FESS, Setliff
states �the remedy for surgical anxiety is precision�3.
We have also found this to be true of adenoidectomy, and thus we became
interested in the use of the microdebrider for this purpose. One retrospective
series, comparing adenoidectomy with the microdebrider versus conventional
adenoidectomy with curettes, showed a reduced operative time with the
microdebrider4. In a prospective nonrandomized study at our institutions, we
have also found adenoidectomy with the microdebrider to be faster than that
Powered Partial Adenoidectomy
2
with curettes. The average total operative time for adenoidectomy with the
microdebrider in over 100 patients was 3 minutes and 21 seconds. The actual
tissue removal was completed in under one minute (average 50 seconds) and
the majority of time was spent achieving hemostasis (average 2 minutes 31
seconds). Blood loss and complications were comparable with both techniques5.
In our experience, besides the obvious advantage of speed, we found the
most important advantage of the microdebrider technique to be precision. The
microdebrider affords a degree of control of tissue removal that cannot be
matched by curettes, and therefore the risk of inadvertent tissue removal, with
its aforementioned consequences, is greatly lessened. Adenoidectomy with the
microdebrider is now our procedure of choice. Our operative technique is
discussed.
Surgical TechniqueAfter induction of general anesthesia the patient is orotracheally intubated
with a midline oral ray tube. A shoulder roll is placed, and the appropriately
sized Crowe-Davis mouth gag is placed, opened, and suspended. The opening
of the mouth gag should face towards the surgeon�s dominant hand to allow
unhindered motion of the microdebrider handpiece. At this time, the oral cavity is
evaluated for signs of submucous cleft palate and the length of the palate is
assessed. If the oral cavity is normal and the palate is not too short, then we
prefer to remove roughly 66 to 75% of the adenoidal tissue, with the remainder
left at Passavant�s ridge to ensure adequate velopharyngeal closure. If there are
signs of submucous cleft palate or if the soft palate is unusually short, then less
tissue is removed. With this method of tailoring our adenoidectomy to our
patient�s individual anatomy (�partial adenoidectomy�), we have had good
efficacy and no incidence of velopharyngeal insufficiency.
A red rubber catheter is then placed through one nare and secured for
palatal retraction. The adenoids are visualized with a defogged mirror, and the
microdebrider is held in the dominant hand and positioned at the superior
extent of the adenoid pad. With the shaver off and the blade positioned such
that the window is open, the tool may be used to suction clear any secretions
Figure 1 Figure 2
3
Powered Partial Adenoidectomy
or blood from the field. The shaver blade is then positioned over the tissue to be
removed and is activated in oscillate mode at 3,000 �variable� rpm. The �variable�
setting allows the surgeon to regulate blade speed from the footswitch. Slight
downward pressure may be applied to cleanly separate the adenoid tissue from
the fascia underneath. A sweeping motion has worked the best for us and this
motion is continued from superior to inferior to the desired stopping point above
Passavant�s ridge (Figure 1). Blade speed may be regulated by the variable speed
footswitch. The microdebrider is especially useful for precisely removing tissue
against the tori or within the chaonae, as well as easily controlling the inferior
extent of tissue removal. The adenoidectomy is then completed by achieving
hemostasis, which we perform with the suction electrocautery (Figure 2).
1Christmas DA, Drouse JH: Powered instrumentation in functional endoscopic sinus surgery I:Surgical technique. Ear, Nose, & Throat Journal 75:33-40; Jan 1996.2Parsons DS: Rhinologic uses of powered instrumentation in children beyond sinus surgery.The Otolaryngologic Clinics of North America 29(1): 93-104; Feb 1996.3Setliff, RC: The Hummer: A remedy for apprehension in functional endoscopic sinus surgery.The Otolaryngolic Clinics of North America 29(1): 93-104; Feb 1996.4Koltai PJ, Kalathia AS, Stanislaw P, & Heras HA: Power-assisted adenoidectomy. Archives ofOtolaryngology � Head and Neck Surgery 123:685-688; July 1997.5Murray LN, Fitzpatrick P, Estrada L, & Guarisco JL: Powered Partial Adenoidectomy: A ClinicalTrial. Manuscript in preparation.
Ordering Information
4
Powered Partial Adenoidectomy
18-84008RADenoid BladeSingle use, sterile packaged
Diameter Speed Qty
4.0mm 1,000-3,000RPM 5/box
XPS® Model 2000: System 1 & System 2System 1 includes: Console, STRAIGHTSHOT® Handpiece, Multi-Function Footswitch, & Irrigator Pump
System 2 includes: Console, STRAIGHTSHOT Handpiece, & Single-Function Footswitch
Product Qty Product Qty
18-96000 XPS Model 2000: System 1 1 ea 18-96001 XPS Model 2000: System 2 1 ea
Xomed Mustard TableDesigned for improved suspension
Product Qty Product Qty
37-34500 Mustard Table 1 ea 37-34510 Mustard Table Bed Adaptor 1 ea
Powered Adenoidectomy Surgical Technique Video
Product Qty Product Qty
18-84009 NTSC version (U.S.) 1 ea 18-84009P PAL version (International) 1 ea
RADenoid® & XOMED® are registered trademarks of Xomed.
Patents Pending. ©1998 Xomed Surgical Products, Inc. LIT 11.63 08.98
6743 Southpoint Drive North In Australia 800/ 062-289 In Germany 49/ 8105-37-550Jacksonville, FL USA 32216-0980 In Canada 800/ 710-5201 In the U.K. 44/ 1454-619555904/ 296-9600 � 800/ 874-5797 � www.xomed.com In France 33/ 169-187400
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