Is there a need for a histological examination of the adenoid tissue after adenoidectomy?☆

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Abstract

Objectives

In Germany there is no uniform practice regarding the histological examination of removed tissue after an adenoidectomy. In addition, the unique benefits of routine histological examination of adenoid tissue cannot be ascertained from current literature due to varying opinion and evidence.

Methods

This study was approved by the Medical Association and Ethics Committee in Cottbus, Brandenburg, Germany. We evaluated the pre- and intra-operative examination findings (direct and indirect epipharyngoscopy, digital palpation, intraoperative macroscopic assessment and examination of removed tissue) and the histopathological findings of excised adenoid tissue. A statistical analysis of obtained results was undertaken thereafter.

Results

It was found that in all young patients included in the study, the histological results invariably represented lymphoepithelial hypertrophic mucosa with a varying inflammatory response, matching a clinical picture of adenoid vegetation and in keeping with the pre- and intraoperative investigations and findings.

Conclusion

The characteristic history of adenoid vegetation in combination with a classic pre- and intraoperative clinical examination and an inconspicuous macroscopic examination of removed tissue, renders routine histopathological workup dispensable. On suspicion of deviant pathology a histopathological examination is recommended and should be undertaken.

Introduction

The clinical picture of adenoid vegetation caused by the hyperplasia of the pharyngeal tonsil is owed to an increase in parenchymal cells. This hyperplasia may be associated with a partial or complete mechanical obstruction of the upper airway and the resulting nasal obstruction, with increased mouth breathing can lead to snoring and obstructive sleep apnoea in addition to ventilation disorders with recurrent otitis media and conductive hearing loss. Occasionally, these patients also show partial adenoid facies and in rare cases even suffer with malocclusion. The hyperplastic adenoids are also associated with chronic inflammation of the upper respiratory tract and chronic bronchitis [1], [2], [3], [4], [5].

The tendency to develop a high degree of hyperplasia of the pharyngeal tonsil, especially in childhood, is seen as a sign of strong immunological responsiveness. As part of the natural involution tissue regresses during puberty [6].

For existing adenoid hyperplasia with or without infections, a conservative therapeutic trial of antibiotics is often implemented, coupled with decongestant nasal drops, local steroids and autoinflation treatment of the Eustachian tube. However, this therapy is not evidence-based according to the literature and it may be considered to be inferior to the current surgical procedures; epipharyngoscopy, adenoidectomy and paracentesis, with placement of grommets. Surgical procedures for enlarged adenoids and tonsils have been shown to lead to a significant improvement in the quality of life and a reduction in long-term consequences such as conductive hearing loss and speech delay [4], [5], [7].

Tonsillectomy with or without adenoidectomy is the second most common paediatric surgical procedure performed in the United States, while adenoidectomy alone is the seventh most common procedure [2]. According to the report of the Department for Heath in Germany, 32,007 inpatient tonsillectomies with adenoidectomy and 36,458 adenoidectomy without tonsillectomy in children were performed in Germany in 2011. In addition there are the outpatient adenoidectomy numbers that should be added to this figure. (http://www.gbe-bund.de/).

Traditionally, surgeons sent all specimens for histopathology and many still do. The concept of sending routine histological specimens for examination after tonsillectomy is not new. Weibel questioned this in 1964 and came to the conclusion that an examination should be carried out only for patients over the age of 40 [8]. A survey by the American Society of Paediatric Otolaryngology in 1996 revealed that 56% of respondents routinely sent histopathology specimens after tonsillectomy [9].

Controversy continues to exist regarding the routine histological examination of adenoidectomy specimens. Proponents suggest that among other reasons, missing an important diagnosis such as occult malignancy or granulomatous disease and possible medicolegal consequences argue in favour of this routine analysis. However, others state that we should consider the very low yield of significant histological findings in routine adenoidectomy specimens and its added cost [10], [11], [12], [13], [14].

At the HELIOS Clinics Bad Saarow out up to the present time a routine histopathological workup of the removed adenoid tissue is carried out. In the study presented here, the medical history of the child, pre- and intra-operative examination results as well as the histopathological results of the adenoid tissue specimen were compared and correlated with each other to highlight the potential need and importance of routine histopathological analysis.

Section snippets

Material and methods

After approval by the Medical Association and Ethics Committee in Cottbus, Brandenburg, the study was financed by the HELIOS Research Centre (Research ID 006008). A retrospective analysis of all children and adolescents that underwent an adenoidectomy at the HELIOS Clinics Bad Saarow, Germany, in the period between 01/2012 and 02/2013 was undertaken. 208 patients aged 12 months to 20 years (mean age: 10.16 years, male n = 95, female n = 113) were included in the study. No patients were excluded. We

Results

The medical history obtained for all the patients did not raise suspicion for any malignant processes. Of the 140 patients that could be examined properly with the rigid 120° endoscope preoperatively, all demonstrated a normal, hyperplastic adenoid tissue. In all patients an intraoperative examination of the postnasal space using a McIvor mouth gag and velotraction with flexible silicon tube was performed which elicited normal and typical hyperplastic adenoid tissue in the nasopharynx for all

Discussion

Belonging to Waldeyer's lymphatic ring, adenoids consist of mucosa-associated lymphatic tissue and exert immunological properties on the entire respiratory tract and pharynx. Hyperplasia of the adenoid tissue is formed by proliferation of parenchymal cells and is seen as a sign of a strong immunological reactivity and occurs mainly in childhood and adolescence. This hyperplasia is considered to be multifactorial, with chronic inflammation playing a major role, leading to a vicious cycle of

Conclusions for clinical practice

We believe that routine microscopic examination of adenidectomy specimens, especially in young patients with a normal patient history and normal clinical finding results is unnecessary. This has a huge impact on cost and consumption of resources, manpower and time. Microscopic examination should be undertaken only in selected cases, such as in patients with suspicious clinical findings or in patients with a history of previous malignancy.

Conflict of interest

No conflict of interest and no financial relationships with relevant commercial interests exist for any authors.

Funding

The study was funded by the HELIOS Research ID 006008.

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    • ☆

    Presented in part at the 85th Annual Meeting of the German Society for Otolaryngology, Dortmund, Germany, 28th May–1st June 2014.

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