International Journal of Pediatric Otorhinolaryngology

43 (1998) 115 – 122

Electrocautery versus curette adenoidectomy:

comparison of postoperative results

James Clemens, J. Scott McMurray, J. Paul Willging *

Department of Pediatric Otolaryngology and Maxillofacial Surgery, Children’s Hospital Medical Center,
3333 Burnet A6enue, Cincinnati, OH 45229 USA

Received 11 July 1997; received in revised form 22 October 1997; accepted 27 October 1997

Abstract

Objecti6e: Identify differences in adenoidectomy performed by curettage versus electro-

cautery ablation. Design: To receive adenoidectomy by curettage or electrocautery ablation
38 patients undergoing adenoidectomy or adenotonsillectomy were prospectively random-
ized. The study was completed by 24 patients. All tonsillectomy patients received electro-
cautery dissection of the tonsils. Preoperative and at least 1 month postoperative
video-nasopharyngoscopy was performed. Video tapes were reviewed by the authors blinded
to patient identity and procedure to evaluate choanal obstruction. Preoperative and postop-
erative lateral neck radiographs were obtained. Blood loss and postoperative complications
were recorded. Setting: A single, tertiary care pediatric facility. Inter6entions: Electrocautery
ablation of the adenoid was performed with suction cautery. Curettage was performed with
standard adenoid curettes. Main outcome measured: A grading system for adenoid size was
developed using radiographs and endoscopic parameters. The grade of preoperative and
postoperative adenoid tissue was compared between the curettage and electrocautery abla-
tion groups. Operative blood loss was compared between the groups. The postoperative
course and complications were compared. Results: The preoperative grade of choanal
obstruction in both groups was the same. No differences could be found in the postoperative
grade between the curettage and the electrocautery ablation groups. No postoperative
complications were recorded in either group. The estimated blood loss in the curettage group
was 54.5 ml (S.D. 50.7) while the electrocautery ablation group averaged 3.75 ml (S.D. 6.4;

* Corresponding author. Tel.: +1 513 6364355

0165-5876/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved.

PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 1 5 9 - 6
116 J. Clemens et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 115–122

p= 0.0053). Conclusion: There are no differences in the postoperative results of adenoidec-

tomy performed by electrocautery ablation or curettage. There are no complications
recorded in either group. Estimated blood loss was lower in the electrocautery ablation
group. Decreased blood loss during the procedure makes the electrocautery ablation method
of adenoidectomy attractive. © 1998 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Adenoidectomy; Nasopharynx; Postoperative; Suction electrocautery

1. Introduction

Adenoidectomy continues to be one of the most commonly performed operations

in children in the 20th century. Adenoids are often removed alone or in conjunction
with tonsillectomy and/or with placement of pressure equalization tubes. Obstruc-
tive sleep apnea, recurrent otitis media, otitis media with effusion, sinusitis and
adenotonsillar hypertrophy remain the most common indications for adenoidec-
tomy.
Numerous instruments have been designed for adenoidectomy. For the past 10
years, desiccation by suction electrocautery has been our technique of choice.
Anecdotal review of 10 000 adenoidectomy patients over the past decade has
deemed suction bovie adenoidectomy a safe and effective procedure. The surgical
method of suction electrocautery adenoidectomy is described. The advantages and
disadvantages are outlined and compared with curette adenoidectomy as a stan-
dard.

2. Methods

Between January 1995 and March 1997 34 patients were enrolled in this study.
All patients were given informed consent and enrolled in the study voluntarily. The
study was approved by the institutional review board of this institution.
Patients were recruited for the study if scheduled for elective adenoidectomy
alone or in combination with tonsillectomy, pressure equalization tubes, or other
operative procedures. Patients with chronic illnesses, bleeding disorders, and neuro-
logic disorders were excluded. Patients could withdraw from the study at any time.
After obtaining a complete history and head and neck exam, patients entering the
study were examined with a lateral skull radiograph to measure the adenoid-
nasopharynx ratio. Videonasopharyngoscopy was used to document the size of the
adenoid pad. Nasal endoscopy was performed with a flexible nasopharyngoscope.
The video tapes were reviewed by the authors, blinded to the identity patient and
the method of adenoidectomy
Agrading scale of I – IV was developed (Fig. 1). The scale was based on the
proportion of the choana obstructed by the adenoid pad. Grade I has adenoid
 J. Clemens et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 115–122 117

tissue filling 1/3 the vertical height of the choana; Grade II up to 2/3; Grade III
from 2/3 to nearly all but not complete filling of the choana and Grade IV with
complete choanal obstruction.
The adenoid-nasopharynx ratio was measured radiographically as described by
Fujioka [2] (Fig. 2). The distance from a line parallel to the anterior basiocciput to
the maximal convexity of the adenoid pad is measured. The nasopharynx is then
measured from the anteroinferior edge of the sphenobasioccipital synchondrosis.
The adenoid-nasopharynx ratio can the be calculated. As a ratio, radiographic
technique does not effect the result.
All children were randomized into the suction electrocautery or curette group.
The patients were seen 2 weeks post-operatively. Video-nasopharyngoscopy and a
repeat lateral skull radiograph were then performed at least 1 month post-opera-
tively to document the residual adenoid pad. The preoperative and postoperative
nasal endoscopy sizing grade was compared with the preoperative and postopera-
tive radiographs.
With 12 patients in each group, 24 children completed the study. In the suction
electrocautery group, seven patients completed both preoperative and postoperative
nasopharyngoscopy and radiographic evaluation, three patients had preoperative
and postoperative radiographic evaluation only and two patients completed preop-
erative and postoperative nasopharyngoscopy only. In the curette adenoidectomy
group, nine patients completed preoperative and postoperative nasopharyngoscopy
and radiographic evaluation, two patients completed only preoperative and postop-
erative nasopharyngoscopy, and one patient completed only the radiographic

Fig. 1. Adenoid grading scale for nasopharyngoscopy. The grading scale is based on the amount of
obstruction at the choana when viewed with a nasopharyngoscope. Grade I is obstruction of up to 1/3
of the choana. Grade II is obstruction of 1/3 – 2/3 of the choana. Grade III is obstruction of 2/3 to nearly
complete obstruction of the choana. Grade IV is complete obstruction of the choana by adenoid tissue.
118 J. Clemens et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 115–122

Fig. 2. Grading scale for adenoid measurement by radiograph. The adenoid (A) is measured as the
distance from a line parallel to the anterior basiocciput (B) to the maximal convexity of the adenoid pad
(A1). (See Fig. 2A) The nasopharynx (N) is then measured from the posterior superior edge of the hard
palate (C1) to the anteroinferior edge of the sphenobasioccipital synchondrosis (D1). When the
synchondrosis is not clearly visualized, point (D1) can be determined as the point where the posteroinfe-
rior margin of the lateral pterygoid plates (P) reaches the base of skull. (See Fig. 2B) The adenoid-
nasopharynx ratio (A/N) can then be calculated. As a ratio, the radiographic technique does not effect
the result. [2]
 J. Clemens et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 115–122 119

evaluation. The high attrition rate was from non-compliance in follow-up. Tele-
phone contact could not be made with the patients failing postoperative follow-up.

3. Surgical technique

Suction electrocautery adenoidectomy is performed under general endotracheal

anesthesia. The child is positioned on a shoulder roll and a Blair drape is fashioned.
A Crowe-Davis mouth prop is inserted and suspended from a Mayo stand. The
head is well cradled on the bed. The palate is palpated to ensure the absence of
submucous clefting of the palate. The posterior and lateral nasopharyngeal walls
are palpated for pulsation. A red rubber catheter is passed transnasally and used
for gentle retraction of the soft palate. A nasopharyngeal mirror is used to visualize
the nasopharynx and to guide the surgical dissection.
The suction electrocautery unit (Force 40 S-20; Valley Lab., CO) is set on spray
at 40 Watts. Children weighing more than 50 kg may benefit from 45 Watts, while
children less than 10 kg require 30 Watts. Beginning at the choana in the superior
nasopharynx, the suction electrocautery is applied to the adenoid pad. The suction
evacuates the smoke. As the adenoid is cauterized, its volume shrinks. The
dissection continues until the obstructing adenoid is removed and the peritubal area
is cleared. As in curettage, care is taken around the eustachian tube orifice. In
addition, one must be careful not to burn the soft palate inadvertently, creating a
circumferential nasopharyngeal burn.
If the child has evidence of submucous clefting, neurological disorders, or
hypernasal speech, the inferior aspect of the adenoid pad is left intact. A ‘superior
half’ adenoidectomy frees the choana and peritubal area of obstructing adenoid
while leaving adequate inferior adenoidal bulk to aid in velopharyngeal closure.

4. Results

With 12 in each group, 24 children completed the study. The results are
summarized in Table 1. The average age of children enrolled in the study was 4.9
years (S.D. 2.8) for the suction electrocautery group and 6.9 years (S.D. 4.1) for the
curette group. There were no statistically significant differences between these
groups comparing age, indication, or concomitant procedure.
Student’s t-test was used to compare the operating time, time to follow up,
preoperative endoscopic grade, and postoperative endoscopic grade. No statistically
significant differences could be found between the curette and the cautery groups.
The postoperative result as judged by endoscopy and radiographs was compared to
the preoperative grade for each group. The difference in the preoperative and
postoperative endoscopic grade and the difference between the preoperative and
postoperative adenoid-nasopharynx ratio by radiographic analysis was greater in
the suction electrocautery group than the curette group although not statistically
significant.
120 J. Clemens et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 115–122

Table 1
Comparison of suction electrocauterv versus curette adenoidectomy

Suction electrocautery Curette

X 9S.D. (n) X 9 S.D. (n)

Age (years) 4.9 9 2.8 (n =12) 6.9 94.1 (n = 12)

Total operating room time (min) 45.4 911 (n =12) 50 913 (n = 12)
Blood loss (ml) 3.75 9 6.4 (p = 0.0053) (n =12) 54.5 950 (n =12)
Pre-operative endoscopic grade 3 90.5 (n =9) 3.1 9 0.7 (n =11)
Post-operative endoscopic grade 1.1 9 0.3 (n =9) 1.2 9 0.6 (n =11)
Pre-operative adenoid-NP ratio 0.8 90.1 (n = 10) 0.84 9 0.1 (n =10)
Post-operative adenoid-NP ratio 0.52 9 0.15 (n =10) 0.6 9 0.2 (n =10)
Follow up endoscopy (months) 5 96.7 (n =9) 4.0 9 7.0 (n =11)
Follow up X-ray (month) 8.8 99.7 (n = 10) 8.7 9 10.9 (n =11)

Number of patients =12.

There were no differences in the indications for adenoidectomy in each group. In

the electrocautery group, adenoidectomy was indicated for recurrent otitis media in
three patients, obstructive sleep apnea in eight patients, and recurrent adenotonsil-
litis in one patient.
Adenotonsillectomy was performed in nine of these children and adenoidectomy
with myringotomy and pressure equalization tube placement was performed in
three children. In the curettage group, adenoidectomy was indicated for recurrent
otitis media in two patients and obstructive sleep apnea in ten patients. Adenoton-
sillectomy was performed in ten of these children. Adenoidectomy with myringo-
tomy and pressure equalization tube placement was performed in two patients.
The only statistically significant difference between the groups was estimated
blood loss. The average blood loss in the suction electrocautery group was 3.75 ml
(S.D. 6.4) and was 54.5 ml (S.D. 50.7) in the curette group (t= 3.4397, p= 0.0053).
There was no morbidity reported in either group.

5. Discussion

Adenoidectomy is a safe and effective procedure, regardless of the method

employed. Many different instruments and techniques have been utilized through-
out the history of the procedure. We have analyzed the technique of ablation of the
adenoid pad by suction electrocautery, and compared it to the standard curette
technique.
The groups for electrocautery adenoidectomy and curette adenoidectomy were
well matched for age, diagnosis, adenoid size, and concomitant procedure. There
was no difference in the length of the procedure between the two groups. An
advantage of the suction electrocautery group is decreased blood loss. While the
curette group had a larger total estimated blood loss, there were no physiologic
consequences.
 J. Clemens et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 115–122 121

Suction electrocautery and curettage provide adequate removal of adenoid tissue.

Both the curette and suction electrocautery groups in our study had adenoid-
nasopharynx ratios larger than those reported in the literature [2] as normal for this
age group (0.890.11 in our study group versus 0.58 reported as normal for
children in the age group). The postoperative adenoid-nasopharynx ratio data more
closely approximated the actuarial data reported by Fujioka [2] (0.579 0.15 versus
0.58). Both techniques equally normalized the radiographic adenoid-nasopharynx
ratio.
Another advantage of suction electrocautery adenoidectomy over curette ade-
noidectomy is precise removal of adenoid tissue guided by the nasopharyngeal
mirror. Adenoid tissue obstructing the choana and surrounding the eustachian tube
orifice and be removed with clear visualization without bleeding. There have been
no complications in either group.
Superior half adenoidectomy was described by Birrell [1] in 1966 using the La
Force adenotome. His paper outlines the indications for this technique. Palatal
incompetence due to anatomical defects, trauma, neuromuscular disorders, and
disproportionately short palates are among the indications cited. Superior half
adenoidectomy is routinely used at this institution in patients with these findings.
Using this technique, obstruction of the choana and peritubal region is relieved,
while adenoid bulk at the site of velopharyngeal closure is maintained to minimize
the risk of velopharyngeal insufficiency developing post-operatively.
This study’s weakness is in its small population size. To find statistical signifi-
cance for all the parameters in the study, it has been calculated that 2000 patients
would need to be enrolled. The relatively large number of patients required is due
to the expected small differences between the two surgical techniques. While our
statistics support our assumption that there is little difference between these
techniques, they cannot be used to draw firm conclusions. Our experience with this
method over the past decade in 10 000 adenoidectomies may bolster our conclu-
sions, but remains anecdotal.
Another facet of this study was the development of a nasal endoscopic grading
scale for adenoid size. This scale is based on a view though a flexible or rigid
nasopharyngoscope. The ratio of obstructing adenoid pad from the roof of the
nasopharynx to the soft palate at the depth of the eustachian tube orifice is
measured. This does not measure the extent of the adenoid tissue as it tracks along
the posterior wall of the nasopharynx toward the oropharynx. It does, however,
document the amount of choanal obstruction. This scale compared favorably to the
standard radiographic scale.
The advantages of this method of evaluating the adenoids are that it can be
performed in the office, saving the patient the exposure and expense of a radio-
graph. Further, it is a dynamic study allowing the physician to evaluate the palate
for mobility and submucous clefting and the choana and eustachian tube orifice for
obstruction. We have found nasopharyngoscopy to be a useful tool, providing more
information in our practice in selected patients.
122 J. Clemens et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 115–122

6. Conclusion

Adenoidectomy is a commonly performed and safe procedure. We advocate the

use of suction electrocautery adenoidectomy as it affords better visualization and
more precise removal of the adenoid tissue. Total blood loss is significantly less
when suction electrocautery is used. Further, suction electrocautery adenoidectomy
allows the surgeon to perform a superior half adenoidectomy when a concern for
velopharyngeal insufficiency exists.

References

[1] J.F. Birrell, Palatal disproportion in children, J. Laryngol Otol. 80 (1966) 706 – 717.
[2] M. Fujioka, L.W. Young, B.R. Girdany, Radiographic evaluation of adenoidal size in children:
adenoidal-nasopharyngeal ratio, Am. J. Respir. 133 (1979) 401 – 404.