M.N. Melnikov, A.S. Sokolov, Department of Otolaryngology, Novosibirsk State Medical Academy, State Regional Clinical Hospital. Adenoidotomy is traditionally considered one of the simplest and most common procedures in otolaryngology practice. Under compulsory health insurance, it is assigned a minimal complexity rating. Indeed, in most pediatric patients, a properly performed procedure results in restoration or improvement of nasal breathing. However, according to our data, not all patients who have undergone adenoidotomy experience restoration of nasal breathing in either the immediate or late postoperative periods. A study of parental reports revealed that approximately 20% of children experience some degree of persistent symptoms characteristic of adenoids and adenoiditis. Our data are consistent with the findings of a 30-year-old study by the Children's Clinic of the St. Petersburg Research Institute of Ear, Throat, Nose, and Speech (L.M. Kovaleva, 1994), which found that a study of the long-term results of adenoidotomy in 1,000 patients found a positive effect in only 54.7% of cases, adenoid recurrence in 15.6%, and rhinitis, sinusitis, and a deviated septum as the causes of inability to breathe freely in 29.7%. Based on a literature review, the author rightly points to such factors as anatomical variability in the structure of the nasopharynx, the relationship between the posterior pharyngeal wall and the soft palate, various locations, sizes, and conditions of adenoid vegetations, and, most importantly, the lack of visual control during surgery. Immunological problems, which apparently cause enlargement of the pharyngeal tonsil, can lead to a combination of adenoids and allergic rhinitis, aggravating the course of the underlying disease (M.A. Mokronosova, G.D. Tarasova, 1999). According to G.A. Gadzhimirzaev et al. (1998), allergy combined with ENT pathology in children was recorded significantly more often (25%) than independent allergic rhinitis (16.8%). Adenoids have a significant pathogenetic significance in the development of chronic recurrent rhinosinusitis, tubal dysfunction and exudative otitis media in children (G. Mogi, M. Suzuki, 1998; H. Takahashi et al., 1989). Without dwelling on other consequences of the impact of nasal obstruction due to adenoids on the body of a sick child, it should be noted that methods for increasing the effectiveness of adenoidotomy were attempted as early as the early 1960s. Thus, in 1959, P. Juggenheim developed a method of adenoidotomy performed using a retractor that lifts and pulls down the soft palate, as well as a lighting system and a number of instruments (forceps, scissors, adenotomes of various diameters). However, even with the use of this method, relapses of adenoids were observed (cited from L.M. Kovaleva, 1994). The development and implementation of endoscopic rhinosurgery techniques would seem to create new opportunities for increasing the effectiveness of adenoidotomy. However, in the modern literature there are only isolated reports on new approaches to solving this problem (H.A. Heras, P.J. Koltai, 1998). The advent of shaver technology for tissue resection has significantly expanded the possibilities of both nasal and paranasal sinus surgery, as well as nasopharyngeal surgery. The technique of modern endoscopic adenoidectomy involves the use of a shaver after removing most of the adenoids with a Beckmann adenotome. An endoscope is inserted through one half of the nose, and the tip of the shaver is inserted through the other. Under the guidance of the endoscope, inserted through the nasal cavity to the nasopharynx, the remnants of lymphoid tissue are carefully removed from the dome and lateral wall of the nasopharynx using cutting burrs. Then, after changing the position of the endoscope and shaver burr, the procedure is repeated in the other half of the nasopharynx (A.S. Lopatin, 1998; C.R. Cannon et al., 1999). We believe that this technique, while certainly raising the effectiveness of adenoidectomy to a qualitatively new level, is not without its drawbacks. In particular, the field of view is limited and there is no complete picture of the nasopharynx. Secondly, in the case of large adenoids descending below the level of the hard palate, it is necessary to return to the transoral approach. Thirdly, there is no spatial representation of the state of the posterior ends of the nasal turbinates after the completion of adenoidotomy. Research objectives: 1. To evaluate the nature of endoscopic changes in the nasopharynx after adenoid removal, especially in cases of recurrence. 2. To develop a method of adenoidotomy allowing for the maximum removal of adenoid tissue from the nasopharynx under visual control. 3. To study the state of the posterior nasal cavity after adenoidotomy and develop surgical tactics for cases requiring their correction. To achieve these objectives, we combined the technique of "direct" adenoidotomy with the capabilities of endoscopic rhinosurgery. At the same time, we took into account that the most complete picture of pathological changes is provided by the capabilities of transoral endoscopy with 70° and 90° Hopkins telescopes. Material and methods of the study: We are observing 32 patients suffering from adenoids, aged from 3.5 to 12 years. In them, the technique of intervention with transoral endoscopic control was used. Of the number of operated on, 19 were boys, 13 - girls. The reason for seeking help were symptoms of nasal obstruction accompanied by hearing loss in 12 patients, postoperative relapse of disease symptoms in 11 (within 1-4 months after adenoidotomy using the generally accepted method), obstructive sleep apnea syndrome and relapse after adenotonsillectomy in 1 patient, relapse of adenoids combined with nasopharyngeal papillomatosis - in 1 patient and the desire of the parents to perform the surgical intervention under general anesthesia with a guaranteed result - in 7 patients. During the examination, the diagnosis of adenoids was confirmed on the basis of anterior and posterior rhinoscopy, in 3 older children it was possible to perform nasopharyngoscopy with a 90° endoscope. Twelve patients were found to have otoscopic manifestations of otitis media with effusion: 8 of these had bilateral otitis media and 4 had unilateral otitis media. The diagnosis was confirmed by tone audiometry and tympanometry. A patient with obstructive sleep apnea syndrome (OSA) presented with recurrent grade III pharyngeal and palatine tonsil hypertrophy, cerebral palsy, and recurrent purulent tracheobronchitis. He underwent preoperative preparation, including a sanitizing tracheobronchoscopy, a course of antibiotic therapy, and physiotherapy for 1.5 months before surgery. Two children presented with symptoms of drug-induced rhinitis with characteristic rhinoscopic manifestations. In one child, who had undergone adenoidectomy, multiple soft papillary growths were found on the lateral wall of the nasopharynx and the posterior surface of the soft palate due to adenoid recurrence. All these patients were operated on by us. Technique for endoscopic examination of the nasopharynx and surgery: The procedure was performed under endotracheal anesthesia. After induction of anesthesia and tracheal intubation, the cuff of the endotracheal tube was inflated. A standard mouth dilator with a built-in spatula was inserted, allowing for a clear view of the oropharynx. The laryngopharynx was then additionally packed with gauze to prevent blood from flowing into the vestibule of the larynx and the entrance to the esophagus. A plastic catheter was inserted through the nasal cavity into the pharynx, removed from the oral cavity, and the soft palate was retracted. A 70° endoscope was inserted into the oropharynx, and the nasopharynx was examined and pathological changes were photographed. The telescope was then connected to a video camera, and the surgery was performed under magnified video monitoring on a monitor. Video documentation of pathological changes and the surgical progress was provided, if necessary. During the development phase of this technique, some adenoids were removed using a Beckmann adenotome, and the remaining lymphadenoid tissue was removed using a conchotome. However, we subsequently noticed that the adenotome only removed a small portion of the adenoid tissue, leaving most of it in place. The conchotome procedure took up to 30-40 minutes. Since 1998, we have added an arthrological shaver to our arsenal. It is quite suitable for rhinosurgical procedures, as it has a 4 mm diameter burr and a length of 12 cm. This shaver has a fairly powerful micromotor, as it is designed for cutting articular cartilage. Therefore, since 1998, we have always performed adenoidotomies using a shaver. If necessary, we performed lymphadenoid tissue biopsies from several sites before surgery. However, this is not necessary, as the aspiration system after surgery contains a large number of tissue fragments suitable for histological examination. The shaver tip was inserted through the nasal cavity into the nasopharynx, and under image control on the monitor, the lymphadenoid tissue of the nasopharynx was removed down to the prevertebral fascia. If necessary, hypertrophied lymphadenoid tissue in the area of ??the tubular tonsils was resected in a similar manner, freeing the pharyngeal orifices of the auditory tubes. In cases where pharyngeal tonsil hypertrophy was so severe that the adenoids were located below the soft palate, the surgical intervention was supplemented by inserting the shaver tip through the oral cavity to remove the lower portion of the adenoids. Hemostasis was achieved by temporarily inserting gauze balls with a clamp into the dome of the nasopharynx. In cases of excessive bleeding, high-frequency point bipolar coagulation was used with curved-tip tweezers from Aesculap. Care was taken to avoid creating large coagulated surfaces, as this could lead to an unpleasant nasal odor in the postoperative period. For diffuse bleeding, temporary nasopharyngeal tamponade according to V.A. Debryansky and G.A. Kutin (1998) was used with a YAMIK catheter. A catheter was inserted through the nasal cavity to the nasopharynx, and only the distal balloon was inflated. After visually monitoring the degree of nasopharyngeal block and ensuring that bleeding had stopped, the surgery was completed, the patient was extubated, and anesthesia was resumed. The balloon was left in place for 1-2 hours for postoperative observation. During this time, the patient's consciousness was fully restored, and there was no risk of blood aspiration. Air was removed from the balloon in the ward without removing the catheter. If the patient did not spit out clean blood, the catheter was removed. It should be noted that we only had two occasions when temporarily inserting a YAMIK catheter. Intraoperative endoscopic findings: 1. During the primary surgery, all patients showed a similar pattern of lymphoid tissue distribution in the hypertrophied pharyngeal tonsil: it occupied the dome of the nasopharynx and the posterior wall of the nasopharynx, pressing on the lateral ridges, and sometimes blocking the pharyngeal orifices of the auditory tubes due to a sharp increase in tonsil volume. 2. In cases of adenoid recurrence, the typical lymphoid tissue was loose, growing from the dome of the nasopharynx, and extending onto the lateral walls of the nasopharynx like a "screen," obscuring the choanae. Scars were present on the posterior wall of the nasopharynx; lymphoid tissue was usually absent there. In two cases of adenoid recurrence, we observed changes characteristic of primary adenoids. Due to the absence of scars, we concluded that technical errors occurred during the primary surgery. 3. A patient with recurrent adenoids and nasopharyngeal papillomatosis was found to have pronounced cicatricial changes in the dome and posterior wall of the nasopharynx, mucopurulent discharge in the posterior parts of the nasal cavity, and proliferation of lymphadenoid tissue on the lateral walls of the nasopharynx, against which multiple papillomatous growths extending to the posterior surface of the soft palate were determined. 4. In children suffering from adenoids and exudative otitis media, typical changes described in the first paragraph were noted in half of the observations, while the rest, in addition to adenoid vegetations, had hypertrophy of the tubal tonsils. The following endoscopic findings were the most unexpected: 1. Enlargement of the posterior ends of the inferior and middle nasal turbinates, sometimes accompanied by their cyanosis, was detected in rare cases during intraoperative endoscopy before removal of the adenoids, more often - after removal of the lymphadenoid tissue. While this was evident during preoperative examination in two children with drug-induced rhinitis, no signs of vasomotor rhinitis were detected in the remaining 10. 2. During removal of lymphadenoid tissue, its growth was detected not only from the dome and posterior wall of the nasopharynx, but also from the superior margin of the choanae and the posterior margin of the vomer. This was observed not only during surgeries for recurrent adenoids but also during primary surgeries for grade III adenoids. 3. After adenoid removal, bilateral partial choanal atresia was discovered in a patient with OSA; their diameter was approximately 25% smaller than in other children of this age. Given the nature of the concomitant pathology, the following surgical interventions were performed simultaneously on the patients: myringotomy with shunting of the tympanic cavities - 12 (including bilateral - 8, unilateral - 4), bilateral tonsillectomy - in one patient with sleep apnea syndrome, shaver resection of tubal tonsils - 6, shaver resection of the hypertrophied mucous membrane of the posterior ends of the inferior turbinates - 2, removal of papillomatous growths - 1. Taking into account the endoscopic changes identified in the posterior parts of the nasal cavity, the following methods for their correction were developed. For enlargement of the posterior ends of the inferior turbinates in vasomotor rhinitis, we used pinpoint bipolar high-frequency transoral coagulation. In this case, an almost immediate contraction of the mucous membrane was observed. For coagulation, standard curved bayonet-shaped coagulation tweezers from the high-frequency coagulator kit were used. Forceps were inserted through the mouth, advanced into the nasopharynx under 70° endoscope control, and then lifted, grasping the posterior end of the enlarged inferior turbinate, and coagulating it with an exposure of 1-2 seconds. With certain anatomical variations of the nasopharynx, when the distance between the posterior wall of the nasopharynx and the soft palate was small, performing the operation using the described technique was not possible. In 4 cases, under 70° endoscope control, a sparing resection of a small area of ??the mucosa and the enlarged posterior ends of the inferior turbinates was performed using a shaver burr passed through the nasal cavity. In a patient with partial choanal atresia, the posterior ends of the turbinates were not enlarged. However, full restoration of nasal breathing was unlikely due to the small size of the choanae. Resection of the posterior ends of the inferior and middle turbinates was performed to increase the lumen of the common nasal passage. Treatment results: The postoperative period was the same as after standard adenoidectomy performed under general anesthesia. Patients were discharged the day after surgery. The only exception was a patient who also underwent tonsillectomy. Restoration of nasal breathing was noted in all patients in the early postoperative period and has persisted to this day. No recurrences were observed during follow-up periods ranging from 3 months to 1.5 years. Four patients with otitis exudata continue treatment, while the remaining patients experienced hearing recovery. Tympanostomy tubes were removed in some children, and were rejected spontaneously in the majority. A detailed survey of children and parents who underwent correction of the posterior turbinates in addition to shaver adenoidectomy did not reveal any negative consequences. In a patient with OSA, nasal breathing was restored, and episodes of respiratory arrest during sleep ceased. We are currently conducting rhinomanometry studies in operated patients at various times postoperatively. Обсуждение результатов: Представляется необходимым обсудить следующие вопросы: 1. Место шейверной аденоидотомии в лечении больных аденоидами. Сохраняет ли свои позиции традиционная аденоидотомия? 2. Нужна ли коррекция задних концов носовых раковин при эндоскопической аденоидотомии? Возможно, вазомоторные изменения патогенетически связаны с существующими аденоидами и спонтанно исчезнут после их удаления. 3. Причины рецидивов аденоидов. Всегда ли они связаны с техническими погрешностями после проведения традиционной аденоидотомии? Мы отдаем себе отчет в том, что пока не располагаем значительным числом клинических наблюдений. Работа по накоплению опыта эндоскопических операций в носоглотке и задних отделах полости носа продолжается, однако уже сейчас понятно, что удалось получить результаты, которые раньше были для нас недостижимы. Все оперированные по поводу рецидивов аденоидов в настоящее время излечены. Не ожидая такого результата, до операции мы предупреждали родителей о том, что рецидив возможен и после нашего вмешательства, однако этого не произошло ни в одном из случаев. С другой стороны, представленная методика лечения предполагает использование дорогостоящего оборудования, большой объем предоперационного обследования, трудоемка и требует адекватного анестезиологического обеспечения. Поэтому и в нашей клинике традиционная аденоидотомия сохраняет свои позиции у большинства больных с аденоидами. Несмотря на освоение современных технологий, сотни детей ежегодно оперируются у нас традиционным способом. Мы считаем, что показания к проведению шейверной эндоскопической аденоидотомии возникают в следующих ситуациях: 1. Рецидивы аденоидов после предшествующей аденоидотомии. 2. Аденоиды в сочетании с экссудативным средним отитом, когда необходимо не только удаление вегетаций из купола носоглотки, но и освобождение глоточных устьев слуховой трубы от гипертрофированной лимфаденоидной ткани, а также выполнить одно-, либо двустороннюю миринготомию и шунтирование барабанных полостей. 3. Аденоиды в сочетании с локальной формой хронического гипертрофического ринита (гипертрофия задних концов нижних носовых раковин), либо аденоиды в сочетании с нейро-вегетативной формой вазомоторного ринита. Является дискуссионным вопрос о том, стоит ли одномоментно проводить коррекцию задних концов нижних носовых раковин при сочетании аденоидов и вазомоторного ринита. Наша позиция такова: если больному проводится оперативное вмешательство под наркозом, необходимо стремиться к тому, чтобы оно оказалось последним. Анализ результатов лечения показывает, что в определенной части наблюдений даже после безукоризненно выполненной традиционным способом аденоидотомии приходится в последующем прибегать к вмешательства по поводу вазомоторного ринита. Полученные данные позволяют считать, что далеко не всегда причинами рецидивов аденоидных вегетаций после аденоидотомии являются технические погрешности в ее выполнении. Очевидно, что при определенных особенностях расположения и роста аденоидов, рецидивах аденоидита, применении родителями средств, не предназначенных для лечения заболеваний носоглотки (например, сока чеснока) формируются сращения между гипертрофированной глоточной миндалиной, задним краем сошника и верхним краем хоаны. Проведенная традиционным способом аденоидотомия не может их устранить, и эти оставшиеся фрагменты лимфаденоидной ткани являются причиной так называемых «ложных рецидивов». Кроме того, как бы тщательно не проводилась аденоидотомия, невозможно удалить лимфаденоидную ткань с боковых стенок носоглотки и трубных миндалин, даже разворачивая аденотом в разные стороны. Мы убедились в этом, когда наблюдали в эндоскоп за попытками срезать гипертрофированную в этих участках ткань аденотомом Бекмана. Выводы: 1. Первые результаты шейверной аденоидотомии подтверждают ее высокую эффективность. 2. Патологические изменения в носоглотке при аденоидах разнообразны и требуют дифференцированного подхода к их коррекции. 3. Разработанные приемы воздействия на задние отделы полости носа позволяют достичь одномоментной коррекции всех заинтересованных структур носоглотки и полости носа, что повышает эффективность оперативного вмешательства в целом.