|Year : 2021 | Volume
| Issue : 1 | Page : 52-57
Auditing adenotonsillectomy: The Makurdi, North Central Nigeria, experience
Amali Adekwu1, Michael E Efu2, Francis A Ibiam3, Godwin Obasikene4, Monday Agbonifo5, Vihishima Lawrence6, Sunday Unogwu7, Babarinde A Ojo8
1 Department of Otorhinolaryngology, College of Health Sciences, Benue State University, Makurdi, Nigeria
2 Department of Anaesthesia, College of Health Sciences, Benue State University, Makurdi, Nigeria
3 Department of Ear, Nose and Throat Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakiliki, Ebonyi State, Nigeria
4 Department of Ear, Nose and Throat Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
5 Department of Ear, Nose and Throat Surgery, Irrua Specialist Hospital, Irrua, Edo State, Nigeria
6 Premiere Urgence Internationale, Maiduguri, Borno State, Nigeria
7 Department of Ear, Nose and Throat Surgery, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
8 Department of Anatomical Pathology, College of Health Sciences, Benue State University, Makurdi, Nigeria
|Date of Submission||24-Jul-2020|
|Date of Decision||29-Aug-2020|
|Date of Acceptance||18-Nov-2020|
|Date of Web Publication||28-Apr-2021|
Dr. Amali Adekwu
Department of Otorhinolaryngology, Benue State University, Makurdi, Benue State
Source of Support: None, Conflict of Interest: None
Background: Adenoidectomy, tonsillectomy, or both are a leading cause of surgical admission, especially in children, in otolaryngological practice in the world. This study aimed to audit the demography, symptoms/signs, indications, types of surgery, postoperative outcome, and histopathological evaluation of adenotonsillectomy in Makurdi, Nigeria. Methods: This was a 3-year retrospective study. Record of total surgical procedures was taken and data of patients who had adenoidectomy, tonsillectomy, or both were retrieved. The data extracted included study population demography, symptoms/signs, indication and surgery carried out, postoperative care, and histopathological reports of specimens. The primary outcomes were symptoms/signs, indication, and type of surgery, whereas postoperative management and histopathological examination findings were secondary consideration. Ethical clearance was obtained. The data were analyzed. Results: Two hundred and twenty different types of surgeries were done within the study period. Seventy-two patients (32.7%) underwent adenoid and tonsil surgeries, comprising 46 males and 26 females; age ranged from 1 to 38 years with mean age of 6.63 ±7.78 years. Majority (68.0%) of the patients were ≤5 years old. Snoring and noisy breathing were common presentations. Obstructive adenotonsillar hypertrophy at 63.9% was the most frequent indication for surgery and adenotonsillectomy constituted the most performed procedure. Postoperatively, all the patients had routine antibiotics, analgesics, and were commenced on graded oral feeds. Nine (12.5%) and six (8.3%) patients had postoperative vomiting and fever, respectively. There were no complications of hemorrhage or fatality. The patients were kept for 2 to 3 days. Histopathology results showed follicular hyperplasia (61.1%) and chronic inflammation (38.9%). Conclusion: Adenoid and tonsillar surgeries still constitute common procedures among children in Makurdi and obstructive adenotonsillar hypertrophy and its surgery is commonly encountered with satisfactory outcome. Routine histopathological examination of nonsuspicious adenoid and tonsil specimens should be discouraged.
Keywords: adenoidectomy, Adenotonsillectomy, indication, Makurdi, tonsillectomy
|How to cite this article:|
Adekwu A, Efu ME, Ibiam FA, Obasikene G, Agbonifo M, Lawrence V, Unogwu S, Ojo BA. Auditing adenotonsillectomy: The Makurdi, North Central Nigeria, experience. J Med Trop 2021;23:52-7
|How to cite this URL:|
Adekwu A, Efu ME, Ibiam FA, Obasikene G, Agbonifo M, Lawrence V, Unogwu S, Ojo BA. Auditing adenotonsillectomy: The Makurdi, North Central Nigeria, experience. J Med Trop [serial online] 2021 [cited 2022 Oct 2];23:52-7. Available from: https://www.jmedtropics.org/text.asp?2021/23/1/52/314856
| Introduction|| |
Adenoidectomy, tonsillectomy, or both are a leading cause of surgical admission, especially in children, in general otolaryngological practice in the world. Although there is no documented prevalence of adenotonsillectomy in Nigeria, in the United States, it accounts for more than 500,000 cases per year. Anatomically, the adenoids are found in the roof of the nasopharynx, whereas the tonsils lie within the tonsillar fossae in the oropharynx that is bounded by the anterior and posterior faucial pillars. Laterally, the tonsil is covered by a distinct fibrous capsule that separates it from the superior constrictor muscle and buccopharyngeal fascia. The medial surface is thrown into folds and is called tonsillar crypts that are lined by stratified squamous epithelium., The adenoids and tonsils are immunologically active in early childhood up to 10 years and thereafter atrophies.,
There are several indications for adenoidectomy or tonsillectomy or both, but the most frequent are obstructive sleep apnea syndrome (OSAS) in children and recurrent acute tonsillitis in older children and adults.,, OSAS is diagnosed on polysomnography in a sleep laboratory and manifests with symptoms and signs of difficulty in breathing, snoring, mouth breathing, frequent nasal discharge, apnoeic attacks, fever, restlessness during sleep, daytime somnolence, adenoid facies, and grossly enlarged adenoid/tonsillar hypertrophy among others and if not treated early is associated with failure to thrive, poor academic performance, neurocognitive dysfunction, daytime hyperactivity and inattention, and potentially long-lasting cardiovascular disorder.,,,,, For tonsillectomy, the indications could be therapeutic, diagnostic, and as access for other procedures. Although there is no clear consensus on the necessity or otherwise of histopathological examination of adenoid/tonsils specimen,, we routinely carry it out in our center. In light of these, we propose to audit the demography, symptoms and signs, indications, type of surgery, postoperative outcome, and histopathological evaluation of adenotonsillectomy in our center.
| Patients and methods|| |
This was a 3-year retrospective study undertaken from January 3, 2015 to December 31, 2018. The record of total surgical procedures was taken from operation registers and data of patients who had adenoidectomy, tonsillectomy, or both were retrieved from their medical records. The data extracted into Excel spreadsheet included study population demographics, symptoms and signs, baseline investigations, indication for and type of surgery, postoperative management, and histopathological reports of specimens. The symptoms ranged from snoring, noisy breathing, mouth breathing, frequent nasal discharge, recurrent sore throat, fever, apnoeic attacks, failure to thrive, daytime somnolence, daytime hyperactivity, poor academic performance, restlessness during sleep, otalgia to halitosis, signs of adenoid facies, small for age, enlarged adenoids, and/or tonsils. These surgeries were performed by a highly experienced particular surgeon using the ‘cold’ dissection technique for the tonsils and adenoid curettes to remove the adenoids. Hemostasis was achieved with adrenaline gauze packs, ligature ties, or bipolar diathermy cautery. The primary outcomes were symptoms and signs, and indication for and type of surgery, whereas postoperative management and histopathological examination findings were secondary considerations. Ethical clearance was obtained from the Health Research Ethics Committee of Benue State University Teaching Hospital, Makurdi before the commencement of the study. The data were analyzed using SPSS version 23.0 and results are expressed in Tables and Figures.
| Results|| |
A total of 220 different types of ear, nose, and throat (ENT)-related surgeries were carried out within the study period. Seventy-two patients (32.7%) underwent adenoid and tonsil surgeries, comprising 46 males and 26 females; age ranged from 1 to 38 years with mean age of 6.63 ±7.78 years. Majority (68.0%) of the patients were 5 years old or less. The patients or their care-givers belonged to various social strata [Table 1]. All the patients had baseline investigations of full blood count; urea, electrolyte, and creatinine (U/E/Cr); and clotting profile [Prothrombin Time (PT), Partial Thromboplastin Time with Kaolin (PTTK), International Normalized Ratio (INR)]. Fifty-nine (81.9%) patients who were 10 years old or younger had additional X-ray of the postnasal space. The symptoms of snoring [55 (76.4%)], noisy breathing [50 (69.4%)], mouth breathing [46 (63.9%)], and apnoeic attacks [44 (61.1%)] were the common presentations [Figure 1]. Patients with symptoms and signs suggestive of obstructive adenotonsillar hypertrophy at 63.9% accounted for the most frequent indication for surgery and by implication, adenotonsillectomy constituted the most performed procedure [Table 1] and [Figure 2]. Hemostasis was achieved using an adrenaline pack (1:200,000) in 39 (54.2%) patients, ligature ties in 25 (34.7%) paients, and bipolar diathermy cauterization in eight (11.1%) patients. Postoperatively, all the patients had routine antibiotics (ampicillin/cloxacillin or ceftriaxone) and analgesics (pentazocen, acetaminophen, or ibuprofen), and were initially commenced on an ice cream diet and thereafter graded oral feeds. Nine (12.5%) patients had postoperative vomiting during anesthetic recovery. No complications of hemorrhage or fatality were recorded. The patients were kept for 2 to 3 days.
|Table 1: Biodata, diagnosis, routine investigations, type of operation, histology, and postoperative outcome|
Click here to view
| Discussion|| |
In Makurdi, adenoid- and tonsil-related surgeries accounted for 32.7% of ENT surgeries during the study period that is lower than the 75% outpatient surgery rate recorded by Al-Shagahin et al. in their work on 419 patients in Jordan. These surgeries were reported to be the most commonly performed in children by otolaryngologists in Nigeria and other parts of the world.,, This study found snoring, noisy breathing, mouth breathing, apnoeic attacks, and adenoid facies as common presentations of obstructive adenotonsillar hypertrophy that is the most frequent indication for surgery and adenotonsillectomy to be the most performed procedure in this series. Other researchers documented similar findings in their works.,,,,,, However, Ryczer et al. in their study in Poland stated that adenoidectomy was performed more in their series. Al-Shagahin et al. documented that recurrent tonsillitis and tonsillar hypertrophy were the two prominent indications for surgery and a slight predominance of adenotonsillectomy over the other types of surgery.
Our study found that children 0 to 10 years old were the most affected by these pathologies accounting for 81.9% with the peak seen in the 5 years or younger age group (68.0%) and there was also male preponderance. Onakoya et al. and Ryczer et al. found 75% and 87.8%, respectively, of their study populations to be 10 years old or younger, whereas Al-Shagahin et al. had 93% of their study populations to be 10 years old or younger. They all documented male predominance but opined that it was not statistically significant. However, Adekwu et al. in an earlier study on preoperative hemostatic assessment in similar surgeries reported 92.1% of their patients to be 10 years and younger with a slight female preponderance.
We found no unusual pathology in the examined specimens as all the reports turned out to be follicular hyperplasia (61.0%) or chronic inflammation (39.0%). Although there is no consensus on the relevance or otherwise of routine histopathological examination of adenoid/tonsil specimens, many researchers have argued against its importance especially in children, as most of their samples turned out to be benign pathologies.,,,,, However, many other authors recommended that when there are suspected cases of malignancy such as unilateral tonsillar enlargement, previous history of head and neck malignancy, ulcerated tonsils suspicious of malignancy, comorbidity of acquired immune deficiency syndrome (AIDS), those with history of transplant surgery, unexplained weight loss, or constitutional symptoms, and neck nodes/masses, the specimens should be subjected to histopathological examination.,,, With our findings, we tend to agree with those that argue against a routine histopathological examination of these specimens especially in a resource-poor setting like ours in which every medical service rendered is out-of-pocket payment.
Most of our patients had uneventful postoperative experience and were initially commenced on an ice cream diet when fully out of anesthesia and later on graded oral feeds. Few (12.5%) patients had a single episode of vomiting during anesthetic recovery that was controlled without medication. Another 8.3% of patients had a fever but tested positive for malaria parasites and were successfully treated with an antimalarial. Fever, nausea, and vomiting in the postoperative period of adenoid and tonsils surgeries are common events as documented by Guerra et al.
Postoperative analgesia was effectively achieved in all our patients with pentazocen, acetaminophen, and/or ibuprofen. Routine usage of prophylactic antibiotics in our patients may have prevented postoperative infection that could prolong hospital stay and increase treatment cost. However, there is controversy on the benefits or otherwise on the use of antibiotic agents in post adenotonsillectomy or tonsillectomy morbidity. Although some authors believed it is helpful, others said it was not necessary.,
Although 5.6% patients of our series had a deranged clotting profile, there were no complications of intra- or postoperative bleeding or fatality. Intraoperative hemostasis was achieved for all the patients by the use of adrenaline gauze packs, ligature ties, or diathermy cautery. Adekwu et al. and Onakoya et al. have disputed the relevance of routine clotting profile in adenoid and tonsillar surgeries in their previous articles as patients who had deranged results did not necessarily manifest perioperative hemorrhage. They advocated that this investigative tool should be reserved for those with a positive family history of bleeding disorder who could afford it. All the patients were discharged within 2 to 3 days and followed up visits at 2 and 4 weeks revealed good healing and symptom relief. Postoperative tonsillectomy bleeding is a potentially life-threatening complication that has been documented by researchers and constitutes about 1.9% to 5.5%., Duration of hospital stay post adenotonsillectomy varies worldwide and from surgeon to surgeon. It ranges from a few hours to several days. In Germany, it is between 5 and 7 days, and in Ireland, they keep their patients overnight (1.37–1.51 days). Many surgeons in parts of the United States and the United Kingdom have canvassed for day-case tonsillectomy in order to save the cost of health care service,, but we could not risk that in our environment because most of our patients came from the remote hinterlands where there were poor access roads and transport challenges. Moreover, patients with obstructive symptoms that were predominant presentations in our series are considered by some researchers as a contraindication for day-case tonsillectomy because of the increased risk of intraoperative respiratory challenges.,
| Limitation to the study|| |
The nonavailability of polysomnography and sleep laboratory in our center made the diagnosis of OSAS to be subjective as the diagnosis was only based on symptoms and clinical findings.
| Conclusion|| |
Adenoid and tonsillar surgeries are still common procedures undertaken among the pediatric age group in Makurdi, symptoms and signs of obstruction are frequent presentation, and obstructive adenotonsillar hypertrophy and its surgery are commonly encountered with a vastly satisfactory outcome. Routine histopathological examination of nonsuspicious adenoid and tonsil specimens should be discouraged in order to save cost.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bluestone CD. Current indications for tonsillectomy and adenoidectomy. Ann Otol Rhinol Laryngol 1992;101:58-64.
Bhattacharyya N, Lin HW. Changes and consistencies in the epidemiology of pediatric adenotonsillar surgery, 1996-2006. Otolaryngol Head Neck Surg 2010;143:680-4.
Casselbrant ML. What is wrong in chronic adenoiditis/tonsillitis anatomical considerations? Int J Pediatr Otorhinolaryngol 1999;49:S133-5.
Richtsmeier WJ, Shikhani AH. The physiology and immunology of the pharyngeal lymphoid tissue. Otolaryngol Clin North Am 1987;20:219-28.
Okafor BC. Tonsillectomy: an appraisal of indications in developing countries. Laryngoscope 1983;96:517-22.
Somefun AO, Nwawolo CC, Mozoi AE, Okeowo PA. Adenoid and tonsil operations: an appraisal of indications and complications. Niger J Surg 2000;7:16-19.
Nieminen P, Löppönen T, Tolonen U, Lanning P, Knip M, Löppönen H. Growth and biochemical markers of growth in children with snoring and obstructive sleep apnea. Pediatrics 2002;109:e55.
Everett AD, Koch WC, Saulsbury FT. Failure to thrive due to obstructive sleep apnoae. Clin Pediatr 1987;26:90-92.
Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics 1998;I02:616-20
Owens J, Opipari L, Nobile C, Spirito A. Sleep and daytime behavior in children with obstructive sleep apnoae and behavioural sleep disorders. Pediatrics 1998; 102:1178-82.
Amin RS, Kimball TR, Bean JA et al.
Left ventricular hypertrophy and abnormal ventricular geometry in children and adolescents with obstructive sleep apnoae. Am J Respir Crit Care Med 2002;165:1395-9.
Ibekwe MU, Onotai LO. Routine histopathologic evaluation of adenoidectomy/or tonsillectomy specimens in Nigerian children: how relevant? J Med Med Sci 2012;3:179-83.
Williams MD, Brown HM. The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21years old and younger. Hum Pathol 2003;34:1053-7.
Al-Shagahin HM, AlBtoush O, Alrawashdeh B, Alsunna Z, Ababseh S. Day-case tonsillectomy in children: experience from a teaching hospital in Jordan. Int J Surg Open 2019;19:1-4.
Afolabi OA, Alabi BS, Ologe FE, Dunmade AD, Segun-Busari S. Parental satisfaction with post adenotonsillectomy in the developing world. Int J Pediatr Otorhinolaryngol 2009;73:1516-9.
Onakoya PA, Nwaorgu OGB, Abja UM, Kokong DD. Adenoidectomy and tonsillectomy: is clotting profile relevant? Nig J Surg Res 2004;6:34-36.
Adekwu A, Adoga AS, Gav TA. Our experience with preoperative haemostatic assessment of paediatric patients undergoing, adenotonsillectomy at Federal Medical Centre, Makurdi. Afr J Paediatr Surg 2016;13:69-72.
] [Full text]
Ryczer T, Zawadzka-Głos L, Czarnecka P, Sobczyk K. Bleeding as the main complication after adenoidectomy and adenotonsillotomy. New Med 2015;19:125-9.
Alvi A, Vartanian AJ. Microscopic examination of routine tonsillectomy specimens: is it necessary? Otolaryngol Head Neck Surg 1998;119:361-3.
Mohamad I, Hassan S, Salim R. The routine histopathological examination of tonsillectomy specimens at Hospital Universiti Sains Malaysia − a retrospective study and its implication. Malays J Med Sci 2007;14:53-55.
Aksakal C, Muslehiddinoglu A. Comparison of routine histopathological examination results in children and adults after tonsillectomy and/or adenoidectomy. Turk Arch Otorhinolaryngol 2018;56:170-73.
Adeyemo A, Okolo C, Ogunkeyede S. Evaluation of histopathology examination of routine tonsillectomy and adenoidectomy specimens in developing countries. J Pediatr Sci 2011;3:e96.
Beaty MM, Funk GF, Karnell LH et al.
Risk factors for malignancy in adult tonsils. Head Neck 1998;20:399-403.
Erdag TK, Ecevit MC, Guneri EA et al.
Pathologic evaluation of routine tonsillectomy and adenoidectomy specimens in the paediatric population is it really necessary? Int J Otorhinolaryngol 2005;69:1321-5
Younis R, Hesse S, Anand V. Evaluation of the utility and cost effectiveness of obtaining histopathologic diagnosis on all routine tonsillectomy specimens. Laryngoscope 2001;111:2166-9.
Nelson ME, Gernon TJ, Taylor JC. Pathologic evaluation of routine paediatric tonsillectomy specimens’ analysis of cost effectiveness. Otolaryngol Head Neck Surg 2011;144:778-83.
Guerra MM, Garcia E, Pilan RR, Rapoport PB, Campanholo CB, Martinelli EO. Antibiotic use in postadenotonsillectomy mobidity: a randomized prospective study. Braz J Otorhinolaryngol 2008;74:337-41.
Burkart CM, Steward DL. Antibiotics for reduction of posttonsillectomy morbidity: a meta-analysis. Laryngoscope 2005;115:997-1002.
Telian SA, Handler SD, Fleiser GR, Baranak CC, Weltmore RF, Potsic WP. The effect of antibiotic therapy on recovery after tonsillectomy in children. Arch Otolaryngol Head Neck Surg 1986;112:610-5.
Lowe D, van der Meulen J, Cromwell D et al.
Key messages from the National Prospective Tonsillectomy Audit. Laryngoscope 2007;117:717-24.
Attner P, Haraldsson PO, Hemlin C, Hessen Soderman AC. A 4-year consecutive study of post-tonsillectomy haemorrhage. ORL J Otorhinolaryngol Relat Spec 2009;71:273-8.
Grandhimani P, Jackson IJB. Intraoperative and postoperative management: UK guidelines for day surgery. Surgery 2006;24:346-9.
Mills N, Anderson BJ, Barber C et al.
Day stay pediatric tonsillectomy − a safe procedure. Int J Pediatr Otol 2004;68:1367-73.
Dennis S, Georgallou M, Elcock L, Brockbank M. Day case tonsillectomy − the Salisbury experience. J One Day Surg 2004;14:17-22.
Sanders JC, King MA, Mitchell RB, Kelly JP. Perioperative complications of adenotonsillectomy in children with obstructive sleep apnoea syndrome. Anesth Analg 2006;103:1115-21.
[Figure 1], [Figure 2]