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


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


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


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


37-34500 Mustard Table 1 ea 37-34510 Mustard Table Bed Adaptor 1 ea

Powered Adenoidectomy Surgical Technique Video


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

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