10.14639/0392-100X-N2593
Objectives. To compare pre- and post-operative pure tone audiometric and impedance audiometric analysis following conventional and endoscopic microdebrider assisted adenoidectomy and compare the outcomes.Methods. Patients diagnosed with chronic adenoiditis were divided in groups of 25 each. Patients in the first group underwent conventional curettage adenoidectomy, while those in second group underwent endoscopic microdebrider assisted adenoidectomy. Preand post-operative pure tone and impedance audiometry were performed for all patients and outcomes were compared. Results. The endoscopic microdebrider assisted method resulted in significantly better outcomes compared to conventional curettage. Criteria such as hearing threshold (p value 0.004 at second follow-up), peak pressure (p value 0.045 at first follow-up) and tympanogram (p value 0.016) showed that the endoscopic method was better, while peak compliance (p value 0.340 at first follow-up) did not show any significant difference between groups.Conclusions. The endoscopic microdebrider assisted method for adenoidectomy has a definite advantage of better visualisation resulting in better clearance of tissue, leading to enhanced middle ear function compared to conventional curettage.
text/xml
1827-675X
2593
en
Nayanika Reddy
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
microdebrider assisted
Assessment of middle ear function after conventional or endoscopic microdebrider assisted adenoidectomy
Text.Serial.Journal
https://www.actaitalica.it/
43
Audiology
2023-10-10
2023-04-10
2023-12-19
2023-12-19
417-423
1
Nayanika Reddy
2023/10/10
10.14639/0392-100X-N2593
417
Department of ENT and Head & Neck Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
1827-675X
microdebrider assisted
en
423
Assessment of middle ear function after conventional or endoscopic microdebrider assisted adenoidectomy
https://www.actaitalica.it/article/download/2593/1045
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:417-423; doi: 10.14639/0392-100X-N2593




Audiology


Assessment of middle ear function after conventional
or endoscopic microdebrider assisted adenoidectomy
Valutazione della funzione dell’orecchio medio dopo adenoidectomia convenzionale vs
endoscopica con microdebrider
Oj Giri, Vijendra Shenoy S, Navya Parvathareddy, Praneetha Puvvula, Deeksha Shetty, Nayanika Reddy
Department of ENT and Head & Neck Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education,
Manipal, India


SUMMARY
Objectives. To compare pre- and post-operative pure tone audiometric and impedance au-
diometric analysis following conventional and endoscopic microdebrider assisted adenoid-
ectomy and compare the outcomes.
Methods. Patients diagnosed with chronic adenoiditis were divided in groups of 25 each.
Patients in the first group underwent conventional curettage adenoidectomy, while those
in second group underwent endoscopic microdebrider assisted adenoidectomy. Pre- and
post-operative pure tone and impedance audiometry were performed for all patients and
outcomes were compared.
Results. The endoscopic microdebrider assisted method resulted in significantly bet-
ter outcomes compared to conventional curettage. Criteria such as hearing threshold (p
value 0.004 at second follow-up), peak pressure (p value 0.045 at first follow-up) and
tympanogram (p value 0.016) showed that the endoscopic method was better, while peak
compliance (p value 0.340 at first follow-up) did not show any significant difference
between groups.
Conclusions. The endoscopic microdebrider assisted method for adenoidectomy has a
definite advantage of better visualisation resulting in better clearance of tissue, leading to   Received: April 11, 2023
enhanced middle ear function compared to conventional curettage.                                 Accepted: June 5, 2023
                                                                                                 Published online: October 10, 2023
KEY WORDS: adenoidectomy, conductive hearing loss, middle ear ventilation, Eustachian
tube, microdebrider assisted
                                                                                                 Correspondence
                                                                                                 Vijendra Shenoy S
RIASSUNTO                                                                                        Department of Otorhinolaryngology, Kasturba
Obiettivi. Confrontare i risultati dei test audiometrici tonali e di impedenzometria prima       Medical College Mangalore Manipal Academy of
e dopo l’esecuzione di adenoidectomia convenzionale ed endoscopica con microdebrider.            Higher Education, Karnataka State, India
Metodi. Cinquanta pazienti con diagnosi di ipertrofia adenoidea sono stati suddivisi in          Tel. +91 824 2445858
due gruppi di 25. Il primo gruppo è stato sottoposto ad adenoidectomia convenzionale,            E-mail: drvijendras@gmail.com
mentre nel secondo gruppo l’adenoidectomia è stata eseguita con microdebrider sotto
visione endoscopica. Valutazioni audiologiche di audiometria tonale e impedenzometria              How to cite this article: Giri O, Shenoy S V,
sono state eseguite in tutti i pazienti prima e dopo l’intervento, e i risultati sono stati        Parvathareddy N, et al. Assessment of middle ear
confrontati.                                                                                       function after conventional or endoscopic micro-
Risultati. L’adenoidectomia endoscopica ha mostrato risultati audiologici migliori con             debrider assisted adenoidectomy. Acta Otorhi-
una differenza statisticamente significativa per quanto riguarda la soglia uditiva (p value        nolaryngol Ital 2023;43:417-423. https://doi.
0,004 al secondo controllo), la pressione al picco (p value 0,045 al primo controllo), e il        org/10.14639/0392-100X-N2593
timpanogramma (p value 0,016), mentre la compliance al picco (p value 0,340 al primo
                                                                                                 © Società Italiana di Otorinolaringoiatria
controllo) non ha mostrato differenze tra i due gruppi.                                          e Chirurgia Cervico-Facciale
Conclusioni. Rispetto all’adenoidectomia convenzionale, l’adenoidectomia endoscopica
con microdebrider ha il vantaggio di una miglior visualizzazione, che determina una più
                                                                                                                OPEN ACCESS
completa rimozione del tessuto adenoideo e un miglioramento della funzionalità dell’orec-
chio medio.                                                                                      This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
PAROLE CHIAVE: adenoidectomia, ipoacusia trasmissiva, ventilazione dell’orecchio                 Commercial-NoDerivatives 4.0 International) license. The
                                                                                                 article can be used by giving appropriate credit and mentio-
medio, tuba di Eustachio, microdebrider
                                                                                                 ning the license, but only for non-commercial purposes and
                                                                                                 only in the original version. For further information: https://
                                                                                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                         417
O. Giri et al.




Introduction                                                                                widely in surgical treatment of adenoids. Our study aims to
                                                                                            compare the conventional curettage method of adenoidec-
Enlarged adenoids are an important cause for conditions
                                                                                            tomy with the endoscopic microdebrider assisted technique
such as serous otitis media, obstructive sleep apnoea, Eus-
                                                                                            in terms of post-operative improvement in middle ear func-
tachian tube dysfunction and nasal obstruction. Tradition-
                                                                                            tion.
ally the technique of adenoidectomy has been a transoral
approach with an adenoid curette or adenotome. As this is a
blind procedure, there is always a chance of leaving behind                                 Materials and methods
some adenoid tissue. Hence, attention has been drawn to-                                    This was a prospective observational study conducted
wards an endoscopic microdebrider assisted technique that
                                                                                            among 50 patients aged 5 to 14 years over a 2-year period
involves direct transnasal visualisation and removal of ad-
                                                                                            (Tab. I). Subjects diagnosed with adenoid hypertrophy
enoid tissue by a rigid 0° nasal endoscope. This technique
                                                                                            were divided in two study groups of 25 each, a sample
offers the advantage of direct visualisation of the nasophar-
                                                                                            size that was attained taking into consideration the pro-
ynx which results in more complete removal of adenoid
                                                                                            portions mentioned in various references and clinically
tissue as well as less chance of injury to surrounding struc-
tures. Various studies have been conducted to compare the                                   meaningful difference in proportions of the outcome.
conventional curettage technique for adenoidectomy with                                     Children whose guardian/parents did not give consent for
the endoscopic microdebrider technique in terms of param-                                   myringotomy were included in the study and those not
eters such as completeness of removal of adenoid tissue,                                    willing microdebrider assisted adenoidectomy due to fi-
time required for procedure, amount of blood loss during                                    nancial constraints underwent conventional adenoidec-
the procedure, damage to the surrounding structures, post-                                  tomy. All the cases of adenoid hypertrophy which were
operative pain, recovery time and symptomatic improve-                                      diagnosed clinically and confirmed by x-ray examination
ment following the procedure 1-5. However, there are no                                     were included in the study. Conditions mimicking ade-
conclusive studies on whether the type of technique bears                                   noid hypertrophy clinically like angiofibroma, nasal poly-
a relationship with the improvement in middle ear function                                  posis, nasopharyngeal carcinoma and gross nasal septum
after the surgery 6,7. Although coblator assisted adenoid-                                  deviation were excluded from the study. In each group,
ectomy is currently popular, considering its creditability                                  pre-operative assessment of middle ear function was done
and cost factor, the endoscopic microdebrider is still used                                 using pure tone audiometry and tympanometry for all pa-


Table I. Demographics describing the age, gender and socioeconomic status of the two groups.
 Variables                                                      Conventional (n = 25)                                                    Endoscopic (n = 25)
    Age
      Mean ± SD                                                                   6.68 ± 2.96                                                8.08 ± 2.72
      Median (Q1,Q3)                                                            6.00 (4.50, 8.00)                                         7.00 (6.00, 11.00)
      Min, max                                                                        3, 13                                                     4, 13
      Mann Whitney U                                                                                               214.50
      P value #                                                                                                     0.055
    Gender
      Male                                                                           13 (52%)                                                  19 (76%)
      Female                                                                         12 (48%)                                                  06 (24%)
      Chi square test statistic                                                                                    3.125
      P value $                                                                                                    0.077
    Socioeconomic status
      Low                                                                            18 (72%)                                                  04 (16%)
      High                                                                           07 (28%)                                                  21 (84%)
      Chi square test statistic                                                                                   15.909
      P value $                                                                                                  < 0.001*
#
 : P value is obtained from Mann Whitney U test comparing median age between conventional and endoscopic techniques which is found to be not significant.
$
 : P value is obtained from two sided chi square test seeing the association of gender and socioeconomic status with conventional and endoscopic group. It was found that only so-
cioeconomic status is significant.




418
                                                                     Middle ear function after conventional or endoscopic microdebrider assisted adenoidectomy




tients. Group 1 patients were treated using a transoral ap-                        group had abnormal hearing thresholds vs 20 (40%) in the
proach with conventional curettage adenoidectomy using                             endoscopic approach group. The p value for comparison
St. Clair Thomson’s adenoid curette as they refused mi-                            between groups was 0.047, indicating that the difference is
crodebrider assisted surgery because of increased costs.                           statistically significant. At second follow-up, 12 ears (24%)
Group 2 patients were treated with an endoscopic micro-                            in the conventional curettage group had abnormal hearing
debrider assisted approach and both nasal cavities were                            thresholds, while in the endoscopic microdebrider group
packed with cotton pledgets soaked with 2% lignocaine                              only 2 ears (4%) had hearing thresholds above 15 dB. The
and adrenaline for 15 minutes. Following removal of                                p value for comparison was 0.004 (Tab. II).
the pledgets, a 4 mm 0° Storz rigid nasal endoscope was
passed through the nasal cavities to visualise the naso-                           Peak compliance
pharynx and the adenoid tissue was removed transnasally                            At presentation, 21 ears (42%) in the conventional curet-
under direct vision using microdebrider. Thinning of torus                         tage group had abnormal peak compliance compared to 24
tubaris was done for microdebrider assisted patients. Post-                        ears (48%) in the endoscopic microdebrider assisted group.
operatively, patients were called for two follow-up visits,                        Comparison between groups yielded a p value of 0.549. At
the first after 1 month and the second after 2 months. Pre-                        first follow-up, 7 ears (14%) in the conventional group and
and post-operative pure tone and impedance audiometric                             4 ears (8%) in the endoscopic microdebrider assisted group
parameters were compared. Pure tone average threshold                              had abnormal peak compliance (p value 0.340). At second
was calculated taking into consideration the average of                            follow-up, 4 ears (8%) in the conventional curettage group
500, 1000, 2000, 4000 Hz frequencies. Statistical analysis                         and 3 ears (6%) in the endoscopic microdebrider assisted
of the data was done by using ANOVA (Fischer F test)
                                                                                   group had abnormal compliance (p value 0.697) (Tab. III).
and student’s unpaired T test. A statistical package, SPSS
17 was used for analysis. A p value of less than 0.05 was
                                                                                   Peak middle ear pressure
considered significant.
                                                                                   Out of 50 ears in the conventional curettage group, 38
                                                                                   (76%) had impaired peak middle ear pressure at presenta-
Results                                                                            tion vs 36 ears (72%) in the endoscopic microdebrider as-
Conventional adenoidectomy was performed in 25 patients                            sisted group (p = 0.650). At first follow-up, 15 ears (30%)
and endoscopic microdebrider assisted adenoidectomy was                            in conventional curettage group and 7 ears (14%) in the en-
performed in 25 patients. Both groups were compared in                             doscopic microdebrider assisted group had abnormal peak
terms of various audiological parameters.                                          middle ear pressure (p value 0.045). After 2nd follow-up, 6
                                                                                   ears (12%) in conventional curettage group and 4 ears (8%)
Hearing threshold                                                                  in the endoscopic microdebrider assisted group had abnor-
42 ears (84%) in the conventional adenoidectomy group                              mal peak pressures (p value 0.507) (Tab. IV).
had hearing thresholds higher than 15 dB compared to 40
ears (80%) in the endoscopic microdebrider assisted group.                         Tympanogram
The p value for pre-operative comparison between groups                            In the conventional curettage group, 38 ears (76%) had
was 0.604, which is not statistically significant. After 1st                       a type B or C curve at presentation compared to 39 ears
follow-up, 30 (60%) patients in the conventional curettage                         (78%) in the endoscopic microdebrider assisted group (p


Table II. Comparison between groups in terms of hearing thresholds.
 Group                                         Normal                                   Abnormal                            Mann-Whitney test
                                                                                                                      to compare between the groups
                                                   N. of ears   %             N. of ears            %                              P value
    Presentation                Group 1                8        16                42                84                              0.604
                                Group 2               10        20                40                80                               NS
    First follow-up             Group 1               20        40                30                60                              0.047
                                Group 2               30        60                20                40                           significant*
    Second follow-up            Group 1               38        76                12                24                              0.004
                                Group 2               48        96                 2                4                            significant*
*
    P value is significant; NS: not significant.




                                                                                                                                                        419
O. Giri et al.




Table III. Comparison between the groups in terms of compliance.
    Group                                                       Normal                 Abnormal                     Mann-Whitney test
                                                                                                              to compare between the groups
                                                   N. of ears            %    N. of ears              %                  P value
    Presentation                Group 1               29                 58      21                   42                  0.549
                                Group 2               26                 52      24                   48                   NS
    First follow-up             Group 1               43                 86      7                    14                  0.340
                                Group 2               46                 92      4                    8                    NS
    Second follow-up            Group 1               46                 92      4                    8                   0.697
                                Group 2               47                 94      3                    6                    NS
NS: not significant.




Table IV. Comparison between the groups in terms of peak pressure.
    Group                                                       Normal                     Abnormal                   Mann-Whitney test
                                                                                                                to compare between the groups
                                                   N. of ears            %    N. of ears                  %                P value
    Presentation                 Group 1               12                24       38                   76                   0.650
                                 Group 2               14                28       36                   72                    NS
    First follow-up              Group 1               35                70       15                   30                   0.045
                                 Group 2               43                86        7                   14                significant*
    Second follow-up             Group 1               44                88       6                    12                   0.507
                                 Group 2               46                92       4                    8                     NS
*
    P value is significant; NS: not significant.




value 0.813). After the first post-operative follow-up, 20                        was reported that there is a significant benefit of adenoidec-
ears (40%) in the conventional group and 9 ears in the en-                        tomy in resolution of middle ear effusion in children with
doscopic microdebrider assisted group had a type B or C                           OME, but the benefit to hearing is small and the effects on
curve (p value 0.016). At 2nd follow-up, 10 ears (20%) in                         changes in the tympanic membrane are unknown.
the conventional group and 4 ears (8%) in the endoscopic                          Although adenoid hypertrophy is the most common
microdebrider assisted group had a type B or C curve (p                           cause for OME, it is often multifactorial 9,10. Hence, stud-
value 0.085) (Tab. V).                                                            ies have shown that a short course of steroids is beneficial
                                                                                  in improving middle ear function overweighing the side
Discussion                                                                        effects 10.
                                                                                  Coyle et al. 11 also concluded that adenoidectomy is a useful
Adenoidectomy has been the cornerstone of treatment in
                                                                                  procedure to correct medically resistant chronic OME and
children suffering from otitis media with effusion (OME)
for many decades 8. There have been various researches in                         should be considered as the first line procedure when surgi-
the field of adenoidectomy, but sparse literature is available                    cal treatment is chosen.
on its outcomes on middle ear function. We thus conducted                         However, dissatisfaction of conventional curettage ade-
this study to critically compare middle ear function follow-                      noidectomy for many years has prompted the use of endo-
ing conventional and endoscopic microdebrider assisted                            scopic assisted powered shaver adenoidectomy with micro-
adenoidectomy.                                                                    bebrider in recent times.
Adenoid hypertrophy in children is the most common cause                          Setliff and Parsons, as stated by Christmas 12, introduced mi-
of eustachian tube blockage leading to fluid collection in                        crodebrider use in nasal surgery in 1994. The unique design
the middle ear, i.e. otitis media with effusion leading to de-                    equipped with powered shaver, continuous irrigation and
rangement of middle ear functions, and various modalities                         suction port makes this instrument superior in clearing tissue
of treatment have used to treat it 9.                                             from the field under direct vision with minimal complications.
In a recent Cochrane review by Van den Aardweg et al. 9, it                       Stainslaw et al. 13 found that tissue dissection was more



420
                                                                              Middle ear function after conventional or endoscopic microdebrider assisted adenoidectomy




Table V. Comparison between the groups in terms of tympanogram.
    Group                                                       Normal                             Abnormal                          Mann-Whitney test
                                                                                                                               to compare between the groups
                                                   N. of ears            %            N. of ears              %                             P value
    Presentation              Group 1                 12                 24               38                  76                             0.813
                              Group 2                 11                 22               39                  78                               NS
    First follow-up           Group 1                 30                 60               20                  40                              0.016
                              Group 2                 41                 82                9                  18                           significant*
    Second follow-up          Group 1                 40                 80               10                  20                              0.085
                              Group 2                 46                 92               4                   8                                NS
*
    P value is significant; NS: not significant.




complete and at appropriate depth with a microdebrider                                        improvement in hearing thresholds following endoscopic
compared to the depth being too shallow in the conven-                                        microdebrider assisted adenoidectomy and only 4% of
tional method which leaves behind significant tissue.                                         patients had abnormal hearing threshold in comparison to
Various studies conducted by Murray et al. and Rodigruez                                      the conventional method (24%; p value = 0.004). There
et al. 14,15 demonstrated that endoscopic assisted powered                                    was no significant difference in peak compliance between
shaver adenoidectomy is more effective in cleaning ad-                                        groups, although peak middle pressures were significantly
enoid tissue under direct visualisation; thus requiring                                       improved post-surgery in children undergoing endoscopic
less operating time, causing less blood loss, and provid-                                     microdebrider assisted adenoidectomy compared to the
ing more complete removal of the adenoid tissue and less                                      conventional method.
post-operative pain.                                                                          The initial pre-operative tympanograms of patients showed
By using endoscopic assisted adenoidectomy with a mi-                                         type B and C curves, which were significantly improved
crodebrider, the adenoid remnants along the superior por-                                     (normal type A) in children who underwent endoscopic mi-
tion of the nasopharynx, the choanae and the peritubal                                        crodebrider assisted adenoidectomy in our study.
region can be clearly visualised easily and thus removed                                      Similar studies have evaluated the conversion rates of
completely. Moreover, the likelihood of damage to the Eu-                                     tympanograms by Sarafoleanu et al. 19 in 2010 which re-
stachian tube and/or to the pharyngeal muscles is reduced,                                    vealed a type B curve in 41% of cases, compared with
thereby reducing the post-operative scarring. Haemorrhage                                     type A in 22% and type C in 37% of cases. Re-evaluation
can also be effectively controlled by direct identification of                                after 4 weeks of surgery (classical adenoidectomy) in
bleeding points 16,17.                                                                        their study also documented very good relief of disease
Tympanometry has been a novel approach to study the                                           by subjective and objective evaluation. Another study by
function of the middle ear including middle ear pressures,                                    Mori et al. 20 in 1980 also observed a type B tympanogram
volume and compliance. This study used these modalities                                       in 50% of cases pre-operatively with post-operative con-
to test middle ear function. According to another study,                                      version to type A.
stapedial reflex is considered too sensitive to be used as                                    A few studies suggested to perform myringotomy as a
a screening test in the diagnosis of OME and thus we ex-                                      therapeutic measure for children with OME undergoing
cluded it from our criteria 18.                                                               adenoidectomy. In contrast, our study revealed consider-
All our patients were post-operatively treated with a short                                   able improvement in children with OME undergoing ade-
course deflazacort (15 days) given according to age and                                       noidectomy alone after a short course of steroids as already
weight followed by the combination of montelukast and                                         mentioned.
levocetirizine for 15 days and mometasone nasal spray                                         Thus, clinical outcomes and middle ear function were im-
for 2 months post-operatively. Patients were encouraged                                       proved drastically in children who underwent microdebrid-
to perform Valsalva manoeuver and swallowing exercises                                        er assisted adenoidectomy compared to the conventional
for a period of 2 months. Repeat pure tone audiometry and                                     method.
tympanometry were conducted at both the follow-up vis-                                        The main limitation of this study was differences in cultural
its suggesting improvement of middle ear function in all                                      background which lead to selection bias. Other limitations
group 2 patients and few group 1 patients without need for                                    include lack of long-term follow-up and the small sample
myringotomy by the second visit. They showed significant                                      size.



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O. Giri et al.




Conclusions                                                               domised single-blind study. Indian J Otolaryngol Head Neck
                                                                          Surg 2022;74(Suppl 2):1044-1049. https://doi.org/10.1007/
Adenoidectomy in hypertrophied adenoids with OME is                       s12070-020-02122-2
a simple and effective procedure for resolution of OME               2
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                                                                          ered adenoidectomy: a comparative study. Med J Armed
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clearance of adenoids using a microdebrider with complete                 S0377-1237(09)80089-0
clearance of tissue over the Eustachian tube opening has             3
                                                                          Manhas M, Deva FA, Sharma S, et al. Endoscopic adenoidectomy
a major advantage over the conventional method. Middle                    replacing the outdated curette adenoidectomy: comparison of the
ear function tests, pre- and post-operatively not only give               two methods at a tertiary care centre. Indian J Otolaryngol Head
                                                                          Neck Surg 2022;74(Suppl 3):4788-4794. https://doi.org/10.1007/
a good idea about the operative outcome, but also help in                 s12070-022-03089-y
following up the patient and the disease process. Micro-             4
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significant improvement in middle ear function not only in           5
                                                                          Juneja R, Meher R, Raj A, Rathore P, et al. Endoscopic assisted
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Funding                                                                   pub2
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This study was approved by the Institutional Ethics Com-                  adenoidectomy vs adenoid curette adenoidectomy. Arch Otolaryn-
                                                                          gol Head Neck Surg 2000;126:845-849. https://doi.org/10.1001/
mittee (Kasturba medical college, Mangalore, MAHE) (ap-                   archotol.126.7.845
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