Surgery to remove adenoids under anesthesia: types, how long it takes

When adults get sick, it's bad, but when it comes to a child, it's hard for both the child and his parents. How much worry and anxiety children's illnesses bring to adults. For example, adenoids, which are growths on the tonsils, are diagnosed mainly in children under 12 years of age. These formations, consisting of lymphoid tissue, create noticeable problems for the child as they grow, so at a certain point, there is talk of their removal (adenoectomy). And since adenectomy is a surgical operation, removing adenoids under anesthesia is considered a common practice, preventing various complications during and after the operation.

In principle, anesthesia during surgical intervention on body tissues seems quite logical. But on the other hand, parents who are concerned about the very idea of a surgical operation on a child are particularly sensitive to the idea of administering anesthesia to the baby, which even in adults often causes unpleasant, and in some cases, dangerous symptoms. In this regard, parents have many questions. Is it possible to do without anesthesia during surgery, as was done in the past? To what extent is the use of anesthetics justified during the removal of adenoids? And is it necessary to perform adenoid resection at all, which traumatizes the child's psyche, if this procedure does not exclude the possibility of a relapse of the disease?

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Adenoids: what are they and should they be removed?

Adenoids (or tonsils) are growths of lymphoid tissue on the surface of the tonsils. The lymphoid tissue itself is designed to retain the infectious factor in the upper respiratory tract, preventing it from descending lower, irritating the bronchi and lungs and causing inflammatory processes in them. The formation of strong immunity is also associated with adenoids.

By removing tonsils, a person deprives himself of protection. But on the other hand, if the lymphoid tissue has become inflamed (adenoiditis) due to frequent colds, this means that it itself is now a source of infection.

Yes, inflammation can be fought, but it does not always give a good result. At some point, the chronic inflammatory process can lead to pathological tissue growth (hyperplasia), which, increasing in size, will block the nasal passages adjacent to the back wall of the pharynx.

It is clear that the growth of adenoids to a critical state, when they block the path of air moving through the nasal passages and almost completely block nasal breathing, does not occur in one day. The process develops gradually, passing in its development 3 (and according to some sources 4) stages.

Adenoids of the 1st degree are said to be present when the lymphoid tissue above the tonsils blocks no more than 1/3 of the nasal passages on the back wall of the pharynx. At the 2nd degree of adenoids, the pathological growths block nasal breathing by half or slightly more.

This state of affairs allows the child to breathe through the nose, but it becomes increasingly difficult to do so. If at the first stage the baby breathes normally during the day, and problems with nasal breathing begin only at night (in a horizontal position, during sleep), which is indicated by partial nasal congestion, snoring, restless sleep, etc. Then the second stage is characterized by problems with breathing through the nose even during the day. At night, the baby snores clearly, and during the day tries to keep his mouth open so that air can enter the lungs through it. Attempts to breathe through the nose become increasingly difficult, accompanied by noisy inhalation and exhalation.

And yet, at the first two stages, at least some ability to breathe normally through the nose is preserved, which cannot be said about the 3rd degree of adenoids, when hypertrophied lymphoid tissue blocks the nasal passages inside the pharynx almost completely. Now breathing through the mouth becomes a vital necessity for the child. Breathing with a closed mouth becomes impossible, which means the baby does not close his mouth at all, which contributes to the formation of a specific elongated face shape with a smoothed nasolabial triangle (adenoid face).

But this is not the worst thing. The child's voice changes (it becomes hoarse, nasal), problems with appetite begin, and accordingly with the digestive system, sleep is disturbed, which affects the general condition and physical activity, hearing deteriorates due to the blockage of the Eustachian tube located nearby by the adenoids and the development of an inflammatory process in it.

Due to lack of oxygen (lack of proper breathing, especially at night), cognitive processes and thinking abilities deteriorate (first of all, memory and attention suffer), and academic performance decreases. A seemingly healthy child begins to lag behind in development.

Changes in appearance and voice affect the attitude of the child's peers. After all, children can be cruel, not realizing the consequences of their evil jokes and teasing. A child whose adenoids were not treated or removed in due time begins to have psychological problems (depressive states, isolation, difficulties in establishing contact, etc.).

Removing adenoids under anesthesia or without it is a risk of being left without protection, which means that the infection, getting into the upper respiratory tract, can freely go further into the bronchopulmonary system. But if this is not done, the consequences look even more dire.

In addition, the function of retaining dust, bacteria and viruses is characteristic not only of the adenoids, but also of the nose, for which there are special villi inside the nasal passages. If a child begins to breathe through the mouth, the air does not pass through the nasal passages and does not receive sufficient cleaning and humidification. Inflamed adenoids are not capable of performing a protective function, which means that the respiratory system again remains unprotected.

The absence of nasal breathing due to the proliferation of lymphoid tissue is an indication for the appointment of an operation to remove adenoids. With adenoids of the 3rd degree, the question of conservative treatment no longer arises. Only an operation can help the child, whether the parents want it or not. Adenoiditis and its consequences must be treated in the first two stages. And in order to recognize the disease in time, you need to be attentive to your child, noting all suspicious symptoms and consulting with a pediatrician and otolaryngologist about their occurrence.

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Adenoid removal surgery and its types

Removal of adenoids or adenectomy, despite all the simplicity of the procedure, is considered a serious surgical operation, the need for which arises mainly at the 3rd degree of adenoids. However, in some cases, the operation can be performed earlier, without torturing the child with long-term conservative treatment. Removal of adenoids is also resorted to in the absence of improvement after a course of medication and physiotherapy.

It is very difficult to determine the degree of adenoids only by the symptoms from the words of parents and the baby. The symptoms of all 3 degrees overlap, and the baby can start breathing through the mouth even at the initial stage of adenoiditis, if the tissues of the nose are swollen and cause a feeling of congestion. An external examination of the throat with a flashlight also does not provide enough information, so doctors resort to more informative methods for diagnosing enlarged adenoids:

• Examination of the nasopharynx using a finger (palpation of the adenoids),
• Examination of the condition of the lymphoid tissue above the tonsils using a mirror inserted deep into the oral cavity (posterior rhinoscopy),
• X-ray examination of the nasopharynx and paranasal sinuses,
• Diagnostic endoscopy (examination of the area of adenoid growth using a fibroscope inserted into the nasal passages from the outside).

If stage 3 adenoids are diagnosed, the child is sent for surgery to remove them. The tonsil resection procedure can be performed using various methods.

The very first and somewhat outdated method of performing adenectomy is considered to be manual removal of adenoids. In fact, during the operation, a special knife is used - an adenotome in the form of a loop with sharp edges, with the help of which the overgrown tissues are simply cut off from the surface of the unchanged mucous membrane.

Despite significant drawbacks (rather severe bleeding during surgery and the inability to visually assess the quality of the work), some clinics continue to perform adenectomy using the old method to this day.

By the way, this type of surgery has frequent complications in the form of repeated proliferation of lymphoid tissue if a small area of it was not removed during the operation with an adenotome. The doctor cannot see whether all the tissues have been completely removed, since the operation is carried out practically by touch.

In the old days, when the traditional method of manual adenoid removal was the only way to combat the disease, the operation was performed without anesthesia. Mothers and grandmothers of today's children (as well as male relatives) may still remember the "horror" of seeing blood flowing from the mouth, which overcame even the pain. Maybe that's why they are so worried about their children and grandchildren who are about to undergo tonsillectomy.

Today, parents have a choice, because there are a sufficient number of new, more effective and advanced methods for removing adenoids:

• endoscopic (the operation is performed under the control of an endoscope and the progress of the procedure, as well as the quality of removal of lymphoid tissue, can be monitored using a computer, to the monitor of which the image is transmitted by a mini-camera at the end of the fibroscope),
• electrocoagulation (cauterization of tissue using electric current),
• laser coagulation (pathologically altered tissues are removed and immediately cauterized with a laser beam of a certain intensity, which helps to avoid bleeding; the beam penetrates to a greater depth, which helps to avoid relapse of the disease and infection of the wound),
• cryodestruction (freezing of tissues with liquid nitrogen, as a result of which they die and are removed painlessly and bloodlessly).

Innovative methods have a significantly lower percentage of complications, while adenoid removal is currently performed mainly under anesthesia. This means that the child does not feel pain and discomfort during the operation, and does not experience those feelings and emotions that have long been imprinted as a dark spot in the memory of their parents and other long-grown relatives.

The times of performing adenectomy without anesthesia are gone forever, however, at the insistence of parents, anesthesia may not be administered to the child before the operation. In principle, the choice is always up to the parents: to agree to anesthesia or not, and if the operation is performed under anesthesia, what type of anesthesia to choose.

Types of anesthesia for adenoid removal

Here we come to the main question that worries many parents whose children are to undergo adenectomy. Under what anesthesia are adenoids removed? According to what principle can one or another type of anesthesia be prescribed? Why do modern doctors tend to remove adenoids under anesthesia, if previously this operation was quite successfully performed without the administration of painkillers?

Let's start with the fact that during adenectomy, doctors can use 2 types of anesthesia: local and general. In domestic clinics, local anesthesia is most often used, while abroad, it has long been customary to remove adenoids under general anesthesia. However, anesthesia (and especially general anesthesia) is not suitable for all children, in this case, the operation is carried out either without anesthesia at all, or local anesthesia is used, which does not require intravenous administration, but is applied directly to the mucous membrane in the area of the back wall of the pharynx and tonsils.

Oddly enough, in the memories of adults who had their adenoids removed in the past (naturally without anesthesia), there is practically no mention of severe pain, after all, we are talking about the excision of living tissue. The reason for the loss of such a symptom in the memories is its complete or partial absence. The fact is that lymphoid tissue contains practically no nerve endings, thanks to which we feel pain, heat, cold and other tactile sensations.

Due to the lack of sensitivity of adenoid tissue, the operation to remove them is considered to be practically painless. The question becomes unclear: why do doctors insist on anesthesia in this case?

The reason for such persistence of doctors is not at all the desire to "knock off" more money from patients (after all, anesthesia requires a separate payment). It has psychological reasons. After all, no matter how much you set the child up for the fact that it will not hurt, the sight of the instruments used in surgery and the "white coat" syndrome will still instill fear. And the closer the doctor gets, the more the child will want to cry, scream, or even run away from the "tormentor".

The slightest careless action of the surgeon and nearby tissues may be affected, which have many more nerve endings. Their damage is unlikely to cause much harm to the baby, but the pain may be quite severe. Will the baby be able to sit quietly during the operation in such conditions?

Even minor pain will seem more noticeable if it is reinforced by the sight of one's own blood. And it is not known what is more traumatic for a child's psyche: pain or the sight of blood. In many cases, blood is an even greater irritant than pain, causing a person to feel fear for his or her life.

If we have sorted out the necessity and benefits of anesthesia, the question of which anesthesia to choose for your baby remains open. Many modern clinics and medical centers in our country can already offer a choice: to perform surgery under general anesthesia or limit ourselves to using local anesthetics. All that remains is to decide on the type of anesthesia.

Which anesthesia should I choose?

We are all parents and we wish only the best for our children. Everyone wants their child's adenoid removal surgery to be successful and for the child to not experience discomfort and pain, which adults know firsthand. What should you rely on when deciding on the type of anesthesia on the eve of adenoid removal under anesthesia?

Undoubtedly, when talking about children, the issue of the safety of the anesthesia procedure for the health and life of a small person comes to the fore. It is clear that any anesthetic, getting into the blood or respiratory system of a person, will cause more harm than a local agent, which is absorbed into the blood in smaller quantities. Removal of adenoids under local anesthesia involves the application of anesthetics to the tissues that will subsequently be removed, and the surrounding area. This significantly reduces the sensitivity of the mucous membrane, and with high-quality anesthesia, the baby does not experience any discomfort or pain during the operation.

Local anesthesia can be performed using inhalation agents released in the form of sprays, treating the surface of the pharynx with anesthetic solutions (for example, lidocaine, Tylenol, etc.) or instilling them into the nasal passages. Intravenous and intramuscular injections of anesthetics are not used in the practice of removing adenoids in children.

The advantage of local anesthesia is the possibility of performing the operation on an outpatient basis, since special equipment is not required in this case. After the procedure, the child can go home immediately. Special monitoring of him, as in the case of general anesthesia, is not required.

A big disadvantage of local anesthesia is the ability to see the operation, because the baby remains conscious. No, the child does not feel pain. Even if the anesthesia is poorly performed, minor pain sensations occur only in the case of damage to nearby healthy tissues, there are no nerve endings in the lymphoid tissue. But how can you make a child with the curiosity inherent in all children close his eyes and switch to pleasant thoughts, if people in white coats scurry around him and try to extract something from his mouth that he has not even seen.

Natural curiosity leads to the fact that the child can see blood gushing from the mouth (especially in the case of the classic manual method of adenoectomy) and get very scared even though he will not feel pain. This can negatively affect the outcome of the operation. The child will cry, try to dodge, and the doctor will not be able to effectively remove all the particles of overgrown lymphoid tissue.

The child can be convinced that there will be no pain, but the fear of people in white coats who once hurt him during blood sampling, vaccinations, medical procedures, as well as of surgical instruments under local anesthesia will not go away.

It is this psychological factor that speaks against local anesthesia. But it can be bypassed by general anesthesia, which is considered preferable during adenomectomy. But general anesthesia, as everyone understands, is considered less safe, even though modern anesthetics have significantly fewer contraindications and side effects than previously used drugs.

It's time to consider all the advantages and disadvantages of general anesthesia, and figure out how to ensure that an effective pain relief procedure, allowing the operation to be performed at a high level, does not harm the child.

Adenoid removal under general anesthesia

When the question of choosing anesthesia arises, you want to get as much information as possible about each method of pain relief. Having dealt with the features of application, as well as the advantages and disadvantages of local anesthesia, it is time to get information about general anesthesia, which is popular abroad and in domestic advanced clinics.

Let's start, as is customary, with the advantages of this method. The main advantage of general anesthesia is rightfully considered to be the child's physical and moral calm during the operation. At the time of adenoid removal, the child is already unconscious, which means he can neither see nor hear what is happening. Even if any complications arise (for example, severe bleeding or damage to healthy mucous membranes, accompanied by pain), the little patient will not know about it. When he comes to, the operation will already be over.

The next important advantage is the doctor's calm during adenomectomy, because he will not have to be distracted by the child's reaction, which is almost impossible to predict. The surgeon can calmly do his job, slowly removing lymphoid tissue clusters, leaving no opportunity for it to remind of itself again in the future.

General anesthesia during adenoid removal in children allows to significantly reduce the time of the operation, because the doctor does not have to stop every time the child starts to worry, cry, twitch. No time is spent on calming the little patient.

Doctors consider adenoid removal under general anesthesia using modern inhalation anesthetics to be the safest method, preventing such an unpleasant complication as repeated increase in the volume of lymphoid tissue. In addition, such anesthesia protects the child's psyche, which is also important, because severe nervous shock can cause fluctuations in blood pressure, heart rhythm disturbances, and shock conditions, regardless of the patient's age.

The advantages of general anesthesia include the absolute absence of pain (this is more difficult to achieve with local anesthesia), prevention of the risk of particles of removed tissue entering the respiratory tract, and a relatively low risk of bleeding from damaged tissue (if the child begins to actively move, resisting the doctor's actions, and cry, the likelihood of bleeding increases, as does the risk of damage to healthy tissue).

If bleeding does occur, the doctor can calmly assess the result of the operation and carry out measures to stop the bleeding (this is usually done with the help of nasal tamponade using hemostatic drugs). It is quite problematic to carry out such manipulations with a crying child, as well as to correct the shortcomings.

But in addition to the positive aspects, general anesthesia also has its disadvantages:

• there is a small chance of developing a nosebleed not related to the removal of the tonsils,
• fluctuations in body temperature are possible, which requires medical supervision,
• there is a minimal risk of developing complications such as hearing loss, sleep and speech disorders, migraines (usually such symptoms are temporary),
• a longer, more difficult (not always) period of recovery from anesthesia,
• quite a decent list of contraindications.

It is worth saying that general anesthesia is most preferable for children with an unstable temperament. It is prescribed for intolerance to painkillers used for local anesthesia, as well as in cases where the anatomical structure of the pharynx and the location of the adenoids in it require a special approach to surgery, and surgical intervention may be delayed.

But let's return to the contraindications that do not allow adenoid removal under general anesthesia. This type of anesthesia is not used if:

• acute infectious pathologies occur (due to the risk of spreading the process),
• there are diseases of the upper or lower respiratory tract (in particular, bronchial asthma),
• the child was diagnosed with rickets/hypotrophy,
• purulent rashes were found on the baby's skin,
• the child has an elevated body temperature for unknown reasons,
• the patient suffers from mental disorders,
• there are exacerbations of chronic diseases,
• the child has heart problems that cannot be treated (if it is possible to stabilize the child's condition, the operation is performed after the end of treatment and usually under local anesthesia).
• the baby was vaccinated the day before (the operation is performed no earlier than 2 weeks after the vaccine is administered).

If there are acute pathologies, then the operation using general anesthesia is performed after complete recovery or remission (in the case of chronic diseases). In case of intolerance to inhalation anesthetics used for general anesthesia, the operation is performed without anesthesia or using local agents.

Because general anesthesia has a large number of contraindications and possible side effects (most often nausea, vomiting, dizziness), before it is administered, the child is examined by an anesthesiologist and, if possible, the anamnesis is studied from the medical record, including a certificate of vaccinations, or from the words of the parents. The doctor finds out whether the child has had allergic reactions to drugs and which drugs exactly caused such manifestations. Clinical studies are mandatory, including blood and urine tests, blood clotting indicators, and an electrocardiogram.

Parents and the child are warned that they cannot eat anything the day before the operation. The child can have dinner at about 7 pm, but he will not have to have breakfast. It is also not recommended to drink water on the day of the operation (at least for 3 hours before the adenoid removal procedure).

In preparation for the operation, the child is given sedatives, preferably of plant origin, in the evening and the day before the procedure (usually an hour before the operation). Immediately before the operation, an enema is given and the child is asked to empty the bladder.

To reduce the negative effects of anesthetics for general anesthesia, the child is given an injection of the drugs "Promedol" or "Atropine". Before giving general or local anesthesia, the child and parents are explained what and why the anesthesiologist will do and what sensations the child should have.

Both endotracheal and laryngeal mask anesthesia are suitable for adenomectomy surgery. The latter is used less often, since it somewhat limits the surgeon's actions in the head area, and this type of anesthesia is associated with the risk of pieces of excised adenoids getting into the respiratory tract.

Endotracheal anesthesia for adenoids is done to children much more often. And although this type of anesthesia is associated with some discomfort, and its duration is longer, asphyxia during surgery is practically excluded.

To perform intubation anesthesia, they do not use a breathing mask, but a special intubation tube, through which the smallest particles of drugs enter the baby's respiratory system, capable of causing complete relaxation and medical sleep. So during the operation, the child sleeps peacefully and does not perceive what is happening to him.

The operation to remove adenoids under anesthesia lasts about 20-30 minutes. The dose and type of anesthetics are selected so that the child wakes up after the operation. The operation is considered complete after the bleeding has stopped.

At the end of the procedure, the child is woken up and taken to the ward, where he will come to his senses within 1.5-2 hours. All this time, the anesthesiologist monitors the condition of the little patient. His work ends when the baby comes to his senses, but the child remains under the supervision of doctors for another 2-3 hours, after which he can safely go home.

Post-operative care

As the baby recovers from anesthesia, he may be tormented by nausea and vomiting mixed with bile. These are the side effects of general anesthesia, however, it should be taken into account that their intensity after endotracheal anesthesia is significantly lower than after intravenous administration of the drug. And the negative impact of anesthesia on the body in this case is less.

For some time after the procedure, the child will be lethargic and weak, so physical activity should be limited during this time. If the adenoids were removed without anesthesia, the child is unlikely to experience any discomfort other than fatigue, except that as a result of reflex swelling of the mucous membranes of the nasopharynx, his nose will be stuffy for 1-1.5 weeks. In this case, vasoconstrictor drops and sprays will help, treatment with which should be carried out for at least 5 days.

If a child has a fever, discomfort and a slight sore throat in the postoperative period, paracetamol-based suppositories or syrup will help, which will relieve fever and pain.

The child will be able to eat no earlier than 2 hours after the operation, but it is better to wait a little longer. During the first 2 weeks, it is recommended to follow a diet that includes excluding hot, spicy, sour, salty dishes from the diet due to their irritating effect on the swollen mucous membrane.

For several days, the doctor will recommend replacing hot baths with warm showers, and taking walks away from crowded places where there is a risk of infection. The child can go to kindergarten 2-3 weeks after the operation, and visit the pool no earlier than a month later. Active physical activity and physical education classes in the postoperative period are undesirable. The main conditions for a quick recovery are: high-calorie, vitamin-rich food, quiet walks in the fresh air away from roads and public places, good rest and sleep.

Possible complications after adenomectomy, such as bleeding or re-growth of lymphoid tissue, are most often the result of refusal of anesthesia or use of local agents, when the child simply does not allow the doctor to do his job well. Removal of adenoids under general anesthesia allows avoiding such complications and makes the operation almost imperceptible for the child. Parents can be sure that their child will not subsequently have the same unpleasant memories that tormented them for a long time and became the cause of unnecessary anxiety in the present.

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