Suction diathermy adenoidectomy (interventional procedures consultation)
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE
Interventional procedure consultation document
Suction diathermy adenoidectomy
Adenoids are small lumps of lymphoid tissue at the back of the nose, which are part of the immune system. They are largest in young children and usually disappear by adulthood. An adenoidectomy is an operation to remove the adenoids if they become enlarged and are thought to be causing health problems such as ‘glue ear’. Suction diathermy adenoidectomy is a type of surgery to remove the adenoids using heat and suction.
The National Institute for Health and Clinical Excellence (NICE) is examining suction diathermy adenoidectomy and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. NICE’s Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about suction diathermy adenoidectomy.
This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:
- comments on the provisional recommendations
- the identification of factual inaccuracies
- additional relevant evidence, with bibliographic references where possible.
Note that this document is not NICE’s formal guidance on this procedure. The recommendations are provisional and may change after consultation.
The process that NICE will follow after the consultation period ends is as follows.
- The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
- The Advisory Committee will then prepare draft guidance which will be the basis for NICE’s guidance on the use of the procedure in the NHS in England, Wales, Scotland and Northern Ireland.
For further details, see the Interventional Procedures Programme manual, which is available from the NICE website (www.nice.org.uk/ipprogrammemanual).
NICE is committed to promoting through its guidance race and disability equality and equality between men and women, and to eliminating all forms of discrimination. One of the ways we do this is by trying to involve as wide a range of people and interest groups as possible in the development of our guidance on interventional procedures. In particular, we aim to encourage people and organisations from groups in the population who might not normally comment on our guidance to do so. We also ask consultees to highlight any ways in which draft guidance fails to promote equality or tackle discrimination and give suggestions for how it might be improved. NICE reserves the right to summarise and edit comments received during consultations, or not to publish them at all, where in the reasonable opinion of NICE, the comments are voluminous, publication would be unlawful or publication would otherwise be inappropriate.
Closing date for comments: 20 August 2009
Target date for publication of guidance: November 2009
1 Provisional recommendations
1.1 Current evidence on the safety and efficacy of suction diathermy adenoidectomy is adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit.
1.2 This procedure should be carried out only by surgeons with specific training in the use of diathermy and with understanding of its effects, using diathermy settings that minimise the risk of heat damage to surrounding tissues, which can, rarely, cause damage to the atlantoaxial joint.
2 The procedure
2.1 Indications and current treatments
2.1.1 Adenoidectomy is usually carried out in children, for conditions including nasal obstruction, recurrent otitis media with effusion and obstructive sleep apnoea. Depending on the indication, it is often combined with tonsillectomy and/or grommet insertion.
2.1.2 Traditional adenoidectomy is carried out by ‘cold’ curettage. A potential problem with this technique is persistent bleeding, which may require control by electrocautery or packing of the nasopharynx.
2.2 Outline of the procedure
2.2.1 Suction diathermy adenoidectomy (also known as suction electrocautery or suction coagulation) aims to remove the adenoids while minimising intraoperative blood loss and risk of secondary haemorrhage. It involves the use of heat generated by an electric current to ablate or liquefy adenoid tissue, which is then removed using suction.
2.2.2 The procedure is performed with the patient under general anaesthesia. Direct (using a mirror) or endoscopic visualisation is used. A suction diathermy probe (coagulator) is passed into the mouth and applied to the adenoid tissue in the nasopharynx, to liquefy and remove it. The procedure is judged to be complete when the choanae are clearly visible and the nasopharynx has a smooth contour.
2.2.3 Several different devices are available for this procedure, which may require different diathermy settings to minimise the risk of heat damage.
|Sections 2.3 and 2.4 describe efficacy and safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the overview, available at www.nice.org.uk/IP754overview|
2.3.1 A meta-analysis reported a subjective success rate (definition varied for each study) for 1812 patients treated by suction diathermy across 6 studies of 95% (1721/1812; 95% confidence interval [CI] 92.7% to 97.3%; p < 0.001).
2.3.2 A randomised controlled trial of 100 patients treated by suction diathermy or by curettage reported that suction diathermy-treated patients had significantly fewer Wormald and Prescott grade 3 remnant adenoids than patients treated by curettage at 6‑month follow-up (p = 0.0184) (scale ranges from grade 1 [less than one third of the posterior choanae are obstructed], to grade 3 [more than two thirds of the posterior choanae are obstructed]).
2.3.3 A prospective audit of 126 patients treated by suction diathermy or by curettage used a scale from 0 [best] to 6 [worst] to measure nasal obstruction, snoring loudness and frequency, coloured rhinorrhea duration and presence of irregular sleep patterns. It reported significantly lower mean postoperative symptom scores after both treatments (0.4 and 0.7, respectively) compared with mean preoperative scores (3.3 and 3.0, respectively) (p < 0.001 for both groups). No significant difference in mean symptom score change from baseline was reported between the two treatment groups (absolute figures not stated) (p = 0.07).
2.3.4 A case series reported that 2% (24/1387) of patients treated by suction diathermy remained symptomatic at follow-up between 3 months and 6 months later. The 24 who remained symptomatic had another operation, some concurrently with other surgery (not otherwise described).
2.3.5 The Specialist Advisers listed key efficacy outcomes as reduced blood loss (especially important in small children), completeness of adenoidectomy and relief of symptoms (for example, infection and obstructive sleep apnoea).
2.4.1 In the meta-analysis of 2522 patients treated by suction diathermy or curettage, mean intraoperative blood loss was 4.31 ml (95% CI 0.43 ml to 8.19 ml; p = 0.03; 5 studies) and 24.00 ml (95% CI 0 ml to 48.26 ml; p = 0.052; 3 studies), respectively.
2.4.2 The non-randomised controlled trial of 149 patients reported no postoperative bleeding episodes in patients treated by suction diathermy (0/77) compared with 10% (7/72) in those treated by curettage (p < 0.001). In the prospective audit secondary bleeds (defined in the paper as pink-stained nasal discharge that required no intervention) were reported in 4% (3/68) of patients treated by suction diathermy and 2% (1/58) of those treated by curettage.
2.4.3 Postoperative neck stiffness was reported in the non-randomised controlled trial of 276 patients treated by suction diathermy, curettage, or microdebrider adenoidectomy to have occurred in 9% (8/93), 10% (8/84) and 17% (17/99) of patients respectively (p = 0.08, not stated if ‘overall’ or pair-wise comparison).
2.4.4 Grisel’s syndrome (nontraumatic fixed rotary subluxation of vertebrae C1 on C2) was reported in 1 patient in the retrospective study of 1206 patients and 1 patient in a case report. One of these patients had torticollis and type I atlantoaxial subluxation which resolved in 3 weeks and the other had had a reduced range of neck movement at 9-month follow-up. Retropharyngeal fluid collection resulting in neck stiffness and low‑grade fever was reported by 1 patient in the retrospective study of 1206 patients. Cervical osteomyelitis was reported in 1 patient after suction electrocautery, in a case report: this resolved completely after 4 weeks of medical therapy.
2.4.5 Velopharyngeal insufficiency (improper closing of the soft palate against the posterior pharyngeal wall during speech and swallowing) was reported in 16 patients in the case series of 1206 patients: this resolved within 6 months in all but 1 patient, in whom it persisted for more than 2 years. The prospective audit reported that 4% (3/68) of patients treated by suction diathermy had transient velopharyngeal insufficiency compared with 7% (4/58) of patients treated by curettage: it resolved in all 7 patients within 2–4 weeks.
2.4.6 The Specialist Advisers considered theoretical adverse events to include thermal damage or burns to the nasopharynx and surrounding structures from diathermy, scarring and infection.
3 Further information
3.1 For related NICE guidance see www.nice.org.uk
Chairman, Interventional Procedures Advisory Committee
Personal data will not be posted on the NICE website. In accordance with the Data Protection Act names will be anonymised, other than in circumstances where explicit permission has been given.
It is the responsibility of consultees to accurately cite academic work in order that they can be validated.
This page was last updated: 30 March 2010