Adenoidectomy Surgery in India and UAE | Complete Patient Guide

• **Primary indications for adenoidectomy:**

• Adenoid hypertrophy causing significant nasal obstruction with mouth breathing despite ≥6 weeks of intranasal corticosteroid therapy

• Recurrent acute otitis media: ≥3 episodes in 6 months or ≥4 episodes in 12 months, especially with concurrent adenoid hypertrophy confirmed on flexible nasopharyngoscopy or lateral neck X-ray

• Chronic serous otitis media (glue ear) with bilateral conductive hearing loss >20 dB and adenoid hypertrophy contributing to Eustachian tube dysfunction; typically combined with bilateral myringotomy and grommet insertion

• Obstructive sleep apnoea diagnosed by overnight polysomnography (PSG) showing an Apnoea-Hypopnoea Index (AHI) >1 event/hour in children, with adenoid hypertrophy identified as a primary anatomical contributor

• Chronic adenoiditis with persistent postnasal drip and rhinosinusitis unresponsive to >3 months of medical management

• Recurrent rhinosinusitis with computed tomography (CT) confirming adenoid-related ostial obstruction

• Adults: persistent nasopharyngeal obstruction with confirmed adenoid remnant on flexible nasopharyngoscopy, after exclusion of nasopharyngeal carcinoma by biopsy

• **Required pre-operative diagnostic workup:**

• Flexible fibreoptic nasopharyngoscopy (gold standard for direct visualisation and grading of adenoid hypertrophy on a 4-point scale)

• Lateral neck radiograph (soft-tissue view) — widely used for initial assessment; adenoid-nasopharyngeal (A/N) ratio >0.8 is diagnostically significant

• Overnight polysomnography (PSG) or home sleep apnoea testing (HSAT) when OSA is clinically suspected

• Pure-tone audiometry and tympanometry (Type B tympanogram confirming effusion in glue ear cases)

• Full blood count (FBC), coagulation screen (PT, APTT, INR) — mandatory pre-operative haematological assessment

• Blood group and type

• In adults with atypical presentations: CT nasopharynx and biopsy to exclude malignancy

• Allergy testing (skin-prick test or specific IgE panel) in patients with concurrent allergic rhinitis to guide adjunctive management

• **Absolute contraindications:**

• Submucous cleft palate or overt cleft palate (adenoidectomy would remove the velopharyngeal closure mechanism, causing permanent velopharyngeal insufficiency and hypernasal speech)

• Uncontrolled bleeding diathesis (e.g., haemophilia, von Willebrand disease Type 3) without haematologist co-management and factor replacement

• Active systemic infection with haemodynamic instability

• **Relative contraindications (requiring specialist multidisciplinary review):**

• Bifid uvula or any stigmata of occult submucous cleft palate

• Down syndrome or other craniofacial syndromes with pharyngeal hypotonia (heightened risk of post-operative pharyngeal collapse)

• Sickle cell disease — requires haematology optimisation with haemoglobin S target <30% prior to elective general anaesthesia

• Recent upper respiratory tract infection within 4 weeks (risk of laryngospasm under general anaesthesia; elective surgery should be deferred)

• Child under 12 months of age (increased anaesthetic risk; surgery typically deferred unless OSA is life-threatening)

**1. Traditional Curettage Adenoidectomy (Blind Technique)** The oldest technique uses a St. Clair Thompson or Beckmann adenoid curette introduced transorally and passed blindly into the nasopharynx to scrape adenoid tissue off the posterior nasopharyngeal wall. Haemostasis is achieved by postnasal packing. While still practised in low-resource settings due to speed and low equipment cost, the blind technique has known limitations: incomplete resection (particularly of lateral choanal adenoid tissue near the Eustachian tube cushions), risk of inadvertent injury to the Eustachian tube orifices, and a higher recurrence rate of 10–20% compared to visualised techniques. It is no longer considered the standard of care in high-volume ENT centres.

**2. Endoscopic-Assisted Adenoidectomy with Microdebrider (Power-Assisted Technique — Current Gold Standard)** A 0° or 70° rigid nasal endoscope is introduced transnasally to provide continuous direct visualisation of the nasopharynx. A microdebrider — a powered rotating shaver with simultaneous suction-irrigation — is introduced transorally to remove adenoid tissue under endoscopic guidance. This technique allows the surgeon to identify and preserve the Eustachian tube orifices, remove lateral adenoid tissue that curves into the choanae (a common site of residual obstruction), and achieve a consistently complete resection. Blood loss is typically <20 mL. The visualised approach reduces recurrence rates to <5% and is the preferred technique at accredited centres in both India and the UAE. In the context of concurrent grommet insertion, both procedures are completed in a single anaesthetic episode lasting 20–40 minutes total.

**3. Coblation Adenoidectomy (Plasma-Mediated Ablation)** Coblation (controlled ablation) uses bipolar radiofrequency energy delivered in a saline medium to create a precisely controlled plasma field at the tissue surface. This dissolves molecular bonds in adenoid tissue at a temperature of 40–70°C — dramatically lower than electrocautery (>400°C) or laser — minimising collateral thermal injury to surrounding mucosa, the skull base (where adenoid tissue may abut the pharyngobasilar fascia overlying the prevertebral muscles), and the Eustachian tube orifices. Coblation adenoidectomy is performed under direct endoscopic vision and is associated with less post-operative pain, lower risk of post-operative haemorrhage, and faster mucosal healing compared to electrocautery-assisted techniques. It is the technique of choice for patients with coagulopathy (after optimisation), revision adenoidectomy (where tissue planes are scarred), and in centres with OSA-dominant referral patterns where complete lateral wall clearance is critical.

**4. KTP Laser Adenoidectomy** The potassium-titanyl-phosphate (KTP) laser (532 nm wavelength) can be used under endoscopic visualisation to vaporise adenoid tissue with haemostatic precision. While effective, laser equipment costs limit its widespread adoption, and Coblation has largely replaced laser as the preferred energy-based technique due to superior safety profile at lower tissue temperatures. KTP laser remains available at select tertiary ENT centres in Mumbai, Delhi, and Dubai.

**5. Adenoidectomy Combined with Bilateral Myringotomy and Tympanostomy Tube Insertion (Grommets)** In patients with concurrent glue ear (chronic otitis media with effusion), adenoidectomy is performed simultaneously with myringotomy — a small incision in the tympanic membrane — and insertion of a ventilation tube (grommet). The grommet equalises middle-ear pressure, drains accumulated effusion, and restores conductive hearing within days of surgery. The T-type or Shah grommet is the most commonly used short-term tube (extrudes spontaneously in 6–12 months). Long-term T-tubes are reserved for recurrent effusion. This combination procedure is one of the most commonly performed surgical operations in paediatric ENT practice globally and represents a high proportion of the adenoidectomy cases managed through GAF Healthcare.

**6. Revision Adenoidectomy** Approximately 5–10% of patients require revision surgery due to symptomatic regrowth of adenoid tissue. Revision adenoidectomy carries a marginally higher risk of haemorrhage and Eustachian tube injury due to scarring from the primary procedure. Coblation under endoscopic visualisation is the strongly preferred technique for revision cases. Pre-operative flexible nasopharyngoscopy is mandatory to map residual tissue.

**Phase 1 — Pre-Operative Assessment (Day -7 to Day -1)**

• GAF Healthcare's clinical coordinator receives medical records, imaging, and GP/ENT referral letters and routes them to the appointed ENT surgical team within 24–48 hours.

• Remote pre-operative teleconsultation with the operating ENT surgeon to review nasopharyngoscopy findings, PSG data, audiometry, and coagulation results.

• For international patients, GAF Healthcare facilitates pre-operative blood work and any outstanding investigations (e.g., CT nasopharynx if not yet performed) at a partner diagnostic centre within 24 hours of arrival.

• Pre-operative anaesthesia assessment — paediatric patients undergo a structured airway assessment given the frequent co-existence of OSA, which necessitates heightened post-operative monitoring protocols.

• Nil by mouth (NBM) instructions: 6 hours for solids, 4 hours for breast milk (infants), 2 hours for clear fluids.

• Consent process: The surgeon explains the chosen technique (microdebrider vs. Coblation), the scope of concurrent procedures (grommets if indicated), and potential complications.

**Phase 2 — Day of Surgery (Day 0)**

• Admission to hospital 2 hours prior to the scheduled operative slot.

• Induction of general anaesthesia (GA) via inhalational agent (sevoflurane) in children, or IV induction (propofol-based TIVA) in adolescents and adults.

• Airway secured with a south-facing Ring-Adair-Elwyn (RAE) oral endotracheal tube or laryngeal mask airway (LMA) — positioned to give the surgeon unimpeded transoral access.

• Patient positioned supine with neck extended (Rose position); a mouth gag (Boyle-Davis gag) is inserted to retract the soft palate and expose the oropharynx.

• A 0° rigid nasal endoscope is introduced transnasally and positioned in the nasopharynx for continuous visualisation. Adenoid tissue is removed using the chosen powered instrument (microdebrider or Coblation wand) under direct endoscopic guidance.

• If concurrent grommet insertion is planned, myringotomy and tube placement is completed in the same anaesthetic sitting, typically before the adenoidectomy.

• Total operative time: 20–45 minutes depending on adenoid volume and concurrent procedures.

• Haemostasis confirmed endoscopically. Patient extubated and transferred to the Post-Anaesthesia Care Unit (PACU).

**Phase 3 — Immediate Post-Operative Recovery (Day 0–1)**

• PACU monitoring for 1–2 hours: oxygen saturation, heart rate, blood pressure, pain scores (FLACC scale for children <5 years; NRS for older children and adults).

• OSA patients are maintained on continuous pulse oximetry for a minimum of 6 hours post-extubation; supplemental oxygen is titrated to maintain SpO₂ >95%.

• Analgesia: regular paracetamol (15 mg/kg q6h in children; 1 g q6h in adults) and ibuprofen (10 mg/kg q8h in children; 400 mg q8h in adults); ibuprofen is avoided in children <6 months and in patients with renal impairment. Codeine is NO LONGER recommended in children post-adenotonsillectomy due to risk of respiratory depression in CYP2D6 ultra-rapid metabolisers (WHO and AAO-HNS guidelines).

• Oral fluids introduced within 2–4 hours of surgery once fully awake and alert.

• The majority of straightforward adenoidectomy cases (without concurrent tonsillectomy) are discharged the same day or after one overnight observation stay.

**Phase 4 — Post-Discharge Recovery (Days 1–14)**

• Days 1–5: Mild to moderate throat pain and nasal congestion are expected. A soft, cool diet is recommended (ice cream, yoghurt, mashed foods). Avoidance of hot liquids, hard foods, and strenuous physical activity.

• Days 3–7: Nasal breathing typically begins to improve as post-operative oedema resolves. Halitosis (due to healing eschar in the nasopharynx) is normal and self-limiting.

• Nasal saline irrigation (isotonic saline spray) is commenced from Day 2 to facilitate mucosal healing, reduce crusting, and restore ciliary function.

• Patients with grommets receive specific instructions: strict water exclusion from the ear canals (ear plugs during bathing; avoidance of swimming until surgical review confirms tube patency).

• Days 7–10: Most children return to normal activity levels; school can typically be resumed after Day 10.

• Day 14: GAF Healthcare facilitates a post-operative telemedicine review with the operating surgeon. Nasopharyngoscopy is arranged if any concern regarding residual obstruction or haemorrhage exists.

• Adults typically require 7–10 days before returning to desk-based work.

**Phase 5 — Fit-to-Fly Assessment**

• International patients are assessed for fitness to fly at Day 10–14 post-surgery.

• Key clearance criteria: no active bleeding, no fever, adequate oral intake, resolved significant nasal obstruction, and ability to equalise ear pressure (relevant to cabin pressurisation — particularly critical in grommet patients, where the grommet itself facilitates equalisation).

• GAF Healthcare's coordinator obtains a formal fit-to-fly letter from the surgeon, arranges airport wheelchair/assistance if required for young children, and provides a medical summary document in English for the receiving GP or paediatrician.