Coblator adenoidectomy in pediatric patients: a state-of-the-art review

Vol.:(0123456789)
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Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
h ps://doi.o g/10.1007/s00405-023-08094-7
REVIEW ARTICLE
Cobla o adenoidec omy inpedia ic pa ien s: as a e‑o ‑ he‑a
e iew
Ch is ianCal o‑Hen iquez1,2,9 · Ma íaRuedaFe nandez‑Rueda1,3,9· AinhoaGa cia‑Llibe os1,4,9·
By onMaldonado‑Al a ado1,5· XeniaMo a‑Rojas1,6· An oninoManiaci1,7· GiannicolaIannella1,8·
IgnacioJimenez‑Hue a3
Recei ed: 10 May 2023 / Accep ed: 26 June 2023 / Published online: 26 July 2023
© The Au ho (s) 2023
Abs ac
In oduc ion Adenoid hype ophy is one o he main causes o nasal obs uc ion in ‘child en. Adenoid hype ophy can be
app oached ei he wi h nasal co icos e oids, o su gically when medical ea men ails. Di e en adenoidec omy echniques
ha e been p oposed o educe mo bidi y and su gical isks, wi h a consequen ma ked inc ease in he use o new su gical
p ocedu es in ecen yea s, wi h a p og essi e inc ease in he use o cobla ion. This s a e-o - he-a e iew aims o sys ema i-
cally e iew he cu en li e a u e on he ole o cobla ion in adenoidec omy.
Me hods The selec ion c i e ia included child en submi ed o adenoidec omy wi h cobla o s o he echniques. 11 esea ch
ques ions we e de ined. 4 da abases we e explo ed by ou au ho s: PubMed (Medline), he Coch ane Lib a y, EMBASE
and SciELO. The le el o e idence and quali y o he selec ed a icles we e assessed acco ding o assessed acco ding o he
Quali y Assessmen Checklis o he Na ional Ins i u e o Heal h and Clinical Excellence.
Resul s 20 s udies me he inclusion c i e ia: 2 me analysis, 12 andomized clinical ial, 2 non- andomized clinical ial, 1
p ospec i e coho s udy, and 3 e ospec i e coho s udy. I encompassed a o al popula ion o 8375 pa icipan s. Rega ding
he di e en su gical echniques, 18 s udies (excluding me analysis) pe o med cobla ion (n = 1550), 6 mic odeb idemen
(n = 883), 15 cu e age (n = 4016), and 1 suc ion coagula ion (n = 1926).
Conclusion Cobla o adenoidec omy appea s o o e be e adenoid con ol compa ed o cu e age, wi h a possible, al hough
no con i med lowe a e o e ision su ge y. Simila ly, his g ea e esec ion o adenoid issue seems o be ela ed o a g ea e
educ ion o nasal obs uc ion. The ad an ages o his echnique a e mainly less su gical bleeding—al hough i is no clea
his is a clinically ele an di e ence, and less pos ope a i e pain compa ed o cold cu e age. The di e ence in pain is small,
as adenoidec omy is no a pain ul su ge y in gene al. The e is li le e idence on he con ol o OME and compa ison wi h
o he echniques such as mic odeb ide adenoidec omy.
Keywo ds Adenoidec omy· Adeno onsillec omy· Cobla ion· Cobla o · Powe -assis ed adenoidec omy
* Ch is ian Cal o-Hen iquez
ch is ian.cal o.hen [email p o ec ed]
1 Rhinology S udy G oup o  heYoung-O ola yngologis s
o  heIn e na ional Fede a ions o O o-Rhino-
La yngological Socie ies (YO-IFOS), Pa is, F ance
2 Se ice o O ola yngology, Hospi al Complex o San iago de
Compos ela, San iagodeCompos ela, Spain
3 Se ice o O ola yngology, Hospi al 12 de Oc ub e, Mad id,
Spain
4 Se ice o O ola yngology, Valencia Uni e si y Hospi al,
Valencia, Spain
5 Se ice o O ola yngology, Hospi al Vi gen de los Li ios,
Alcoy, Spain
6 Se ice o O ola yngology, El Bie zo Hospi al, Pon e ada,
Spain
7 Depa men o Medical andSu gical Sciences andAd anced
Technologies ‘‘GF Ing assia’’ ENT Sec ion, Uni e si y
o Ca ania, 95123Ca ania, I aly
8 Depa men o ‘O gani di Senso’, Uni e si y ‘‘Sapienza’’,
Viale Dell’Uni e si à, 33, 00185Rome, I aly
9 Mas e deg ee in hinology andskull base, Uni e sidad
In e nacional de Andalucía, Se ille, Spain
4340 Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
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In oduc ion
Adenoid hype ophy (AH) has been desc ibed as a na u al
esponse o inc eased immunologic ac i i y in ea ly li e [1],
being one o he main causes o nasal obs uc ion in child en
[2]. Fu he mo e, i has been iden i ied as an unde lying ac o
in ecu en o pe sis en o i is media, sinusi is, and obs uc-
i e sleep apnea (OSA). I is well known ha he ou comes
o uppe ai way dys unc ion should no be aken ligh ly as
signi ican uppe ai way diso de s may lead o o he se e e
condi ions such as al e ed c anio acial g ow h and cogni i e
impai men .
AH can be app oached ei he wi h nasal co icos e oids [3],
o su gically when medical ea men ails. Adenoidec omy
is one o he mos common su gical p ocedu es in pedia ic
pa ien s [4], whe he pe o med alone o associa ed wi h o he
su ge ies. This p ocedu e has been epo ed o be as high as
65 pe 10,000 child en in England and 50 pe 10,000 child en
in he Uni ed S a es. [5]
Acco ding o he Ame ican Academy o O ola yngology &
Head and Neck Su ge y (AAOHNS) he indica ions o ade-
noidec omy a e ou o mo e episodes o ecu en suppu a i e
hino hea; sleep diso de s wi h nasal b ea hing obs uc ion;
hyponasali y; O i is media wi h ympanic e usion o mo e
han 3mon hs; malocclusion o o o acial g ow h diso de ;
ca diopulmona y complica ions associa ed wi h uppe ai way
obs uc ion, ecu en acu e and ch onic o i is media wi h ym-
panic e usion. [6]
Di e en adenoidec omy echniques ha e been p oposed o
educe mo bidi y and su gical isks, wi h a consequen ma ked
inc ease in he use o new su gical p ocedu es in ecen yea s.
While he mos commonly used echnique was cold cu e age,
in 2007, his end began o be obse ed in a su ey epo ing
an inc ease in he use o elec ocau e y (26%), mic odeb ide
(20%) and cobla ion (7%) [7]. The e is no mo e ecen da a,
and hese numbe s may be cu en ly di e en .
Cobla ion o ‘con olled abla ion’ was i s desc ibed in
2001 [8], al hough i s use in adenoidec omy began in 2005
[9]. Cobla ion adenoidec omy has gained inc easing a en ion
among o ola yngologis s, as i only hea s up o 60°C, causing
minimal damage o he su ounding issue.
The aim o his s a e-o - he-a e iew is o sys ema ically
e iew he cu en li e a u e on he ole o cobla ion in ade-
noidec omy, including measu able changes and side e ec s o
guide cu en p ac ice, as well as o iden i y knowledge gaps
o conduc u u e esea ch.
Me hods
This e iew was conduc ed in acco dance wi h PRISMA
guidelines. In addi ion, a o mal PROSPERO p o ocol was
published acco ding o he NHS In e na ional P ospec i e
Regis e o Sys ema ic Re iews p io o he s a o he
s udy. The ecommenda ions o he AMSTAR-2 guidelines
we e also ollowed.
Li e a u e sea ch: inclusion andexclusion c i e ia
The c i e ia o conside ing s udies o his sys ema ic
e iew we e based on he popula ion, in e en ion, com-
pa ison, and ou come amewo k (PICOTS).
Pa icipan s: Child en
In e en ion: adenoidec omy
Compa ison: cobla o s o he echniques
Ou comes: any measu able a iable a ibu able o
adenoidec omy. Consequen ly, 11 esea ch ques ions we e
de ined (1) is cobla o adenoidec omy in pedia ic pa ien s
associa ed wi h less in aope a i e bleeding? (2) is cobla o
adenoidec omy in pedia ic pa ien s associa ed wi h highe
ope a i e ime? (3) is cobla o adenoidec omy in pedia ic
pa ien s associa ed o less esidual adenoid o pos ope a-
i e ecu ence? (4) is cobla o adenoidec omy in pedia ic
pa ien s associa ed o less pos ope a i e bleeding? (5) is
cobla o adenoidec omy in pedia ic pa ien s associa ed o
less pos ope a i e pain? (6) is cobla o adenoidec omy in
pedia ic pa ien s associa ed o imp o emen in mucocili-
a y clea ance? (7) is cobla o adenoidec omy in pedia ic
pa ien s associa ed o imp o emen in hinomanome y?
(8) is cobla o adenoidec omy in pedia ic pa ien s asso-
cia ed o imp o emen in eus achian ube unc ion? (9) is
cobla o adenoidec omy in pedia ic pa ien s associa ed o
highe cos ? (10) is cobla o adenoidec omy in pedia ic
pa ien s associa ed o less e ision a e? and (11) is cobla-
o adenoidec omy in pedia ic pa ien s associa ed o mo e
imp o emen in sleep diso de ed b ea hing?
Timing and se ing: wi hou limi a ion
Types o s udies: clinical ials and p ospec i e and e -
ospec i e coho s udies published in pee - e iewed jou -
nals. Case epo s, case se ies, heses, na a i e e iews
and mee ing communica ions we e no included. The e
we e no es ic ions by da e o publica ion ype, and he
esea ch was las upda ed in Decembe 2022. S udies
4341Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
1 3
published in English, Spanish, Ge man, F ench, I alian,
Po uguese, and Spanish we e included.
Exclusion c i e ia consis ed o (1) s udies conduc ed
in synd omic pa ien s; (2) dual publica ions; (3) mixing
o su gical echniques wi hou subg oup analysis (4) mix-
ing o pedia ic pa ien s (< 18yea s) wi h adul s wi hou
subg oup analysis (5) simul aneous pe o mance o onsil-
lec omy wi hou analysis o a iables di ec ly a ibu ed o
adenoidec omy and (6) less han 20 cases wi h cobla o .
Sea ch s a egy
We ollowed he ecommenda ions o he PRISMA s a e-
men o a sys ema ic e iew and sea ched he ollow-
ing da abases: PubMed (Medline), he Coch ane Lib a y,
EMBASE and SciELO. A p ede ined sea ch s a egy was
used: (“Adenoid*” OR “adenoidec omy” OR “adeno on-
sillec omy” OR “pha yngeal onsil”) AND (“cobla *” OR
“plasma” OR “bipola adio equency” OR endoscopic).
Abs ac s o e ie ed a icles we e ho oughly e iewed
by ou au ho s, membe s o he YO-IFOS hinology s udy
g oup (CCH, BMA, XMR, MFR), and hose po en ially
mee ing he inclusion c i e ia we e selec ed o ull- ex
e iew. In case o disc epancies be ween e iewe s ega ding
he selec ion o abs ac s, he co esponding a icles we e
included in he ull- ex e iew phase o inal assessmen .
The e e ences o all selec ed a icles we e also manually
e iewed o iden i y any po en ially missing publica ions.
S udy ex ac ion, ca ego iza ion, andanalysis
Fou au ho s (CCH, BMA, XMR, MFR) independen ly
analyzed a icles mee ing he inclusion c i e ia ex ac ing
ele an da a. Disc epancies we e esol ed by discussion.
Va iables ex ac ed encompassed: sample size, age, su gical
indica ion, su gical echnique, and any measu able ou comes
a ibu ed o adenoidec omy.
Assessmen o s udy quali y
The le el o e idence and quali y o he selec ed a icles
we e assessed. The le el o e idence was g aded acco ding
o he Ox o d Cen e o E idence-Based Medicine le els.
Risk o bias was assessed acco ding o he Quali y Assess-
men Checklis o he Na ional Ins i u e o Heal h and Clini-
cal Excellence: appendix F o quasi-expe imen al s udies
and case se ies; appendix C o andomized clinical ials.
S a is ical analysis
Da a we e analyzed wi h STATA o Macin osh . 15.1
(S a aCo p®). No s a is ical compa isons we e made. STATA
was used o pe o m ma hema ical analysis o mean sample
size and mean age. S a is ical signi icance le el was consid-
e ed a a P alue < 0.05.
Resul s
Sea ch esul s
The ini ial sea ch e ie ed 277 publica ions. A e eading
all i les and abs ac s, 41 s udies we e selec ed o ull ex
e iew. A o al o 20 s udies me he inclusion c i e ia.
6 au ho s we e con ac ed wice wi h he aim o ob ain-
ing missing da a; 1 o hem esponded.
O he pape s selec ed o ull- ex eading, 21 publica-
ions we e excluded o he ollowing easons: ou did no
pe o m cobla ion adenoidec omy; wo p esen ed mixed
echniques wi hou subg oup analysis; wo had a oo small
sample size; h ee due o s udy design; h ee did no epo
any measu able a iable a ibu ed o adenoidec omy;
h ee pe o med simul aneous onsillec omy wi hou ana-
lyzing a iables a ibu ed o adenoidec omy; wo mixed
adul pa ien s and child en; one due o language; one was
a duplica ed s udy. Re e ences in supplemen a y ile 1.
Resul s o  heincluded s udies
A summa y o he selec ed s udies is ep esen ed in sup-
plemen a y ile 2 and Table1.
The sea ch s a egy e ie ed 20 s udies, 2 me analysis
[10, 11]; 12 andomized clinical ial [12–23]; 2 non- an-
domized clinical ial [24, 25]; 1 p ospec i e coho s udy
[26]; 3 e ospec i e coho s udy [27–29].
The e iew, excluding he 2 me analysis, encompassed
a o al popula ion o 8375 pa icipan s. The mean sample
size pe s udy was 465.28 pa ien s. The la ges sample
size was epo ed by Bhanda i e al [28] (n = 5659), and
he smalles (n = 40) by Di Rienzo e al. [22] and Hapalia
e al. [13]
Rega ding he di e en su gical echniques, excluding
he wo me a-analyses, 18 s udies pe o med cobla ion
(n = 1550), 6 mic odeb idemen (n = 883), 15 cu e age
(n = 4016), and 1 suc ion coagula ion (n = 1926).
Only 13 o he 20 selec ed s udies p o ided hei mean
age. Gi en his limi a ion, he mean age adjus ed o
4342 Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
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Table 1 Summa y o he e idence
Ques ion 1: is cobla o adenoidec omy in pedia ic pa ien s associa ed wi h less in aope a i e bleeding?
A ailable e idence Fa o ing: 10 RCT (Hapalia, Balasub amanian, Shapi o, El Tahan,
Singh, Mula czyk, Ozki is, Di Rienzo, Gülšen, Chauhan); 2 NRCT
(salam, Bidaye); 1 p ospec i e coho (Kim); 1 e ospec i e coho
(Gul)
Agains :
No di e ence: 1 me analysis (Sun)
Le el o e idence 1a
Conclusions P obably cobla o is associa ed wi h less bleeding, despi e i could no
be demons a ed in a ne wo k me analysis because o he wide con i-
dence in e als and he e ogenei y o s udies
Ques ion 2: is cobla o adenoidec omy in pedia ic pa ien s associa ed o less pos ope a i e bleeding?
A ailable e idence Fa o ing: 1 RCT (singh), 1 p ospec i e coho (kim -mic odeb ide -)
Agains :
No di e ence:
Le el o e idence 1b
Conclusions Cobla o is associa ed wi h less pos ope a i e bleeding compa ed o
mic odeb ide adenoidec omy. The e is no e idence compa ed agains
cu e e
Ques ion 3: is cobla o adenoidec omy in pedia ic pa ien s associa ed wi h highe ope a i e ime?
A ailable e idence Fa o ing: 8 RCT (Hapalia, Ozki is, balasub amanian, El Tahan, Singh,
Mula czyk, Gülšen, Chauhan); 2 NRCT (Salam, Bidaye), 1 e ospec-
i e coho (Gul)
Agains : 1 RCT (Shapi o); 1 p ospec i e coho (Kim -mic odeb ide -)
No di e ence: 1 me analysis (Ya-Lei Sun); 1 e ospec i e coho
(Sjog en)
Le el o e idence 1a
Conclusions P obably cobla o is associa ed wi h longe ope a i e ime, despi e i
could no be demons a ed in a ne wo k me analysis because o he
wide con idence in e als and he e ogenei y o s udies
Ques ion 4: is cobla o adenoidec omy in pedia ic pa ien s associa ed o less esidual adenoid o pos ope a i e ecu ence?
A ailable e idence Fa o ing: 8 RCT (Hapalia, balasub amanian, Di Rienzo, El Tahan;
Gülšen, Chauhan, Bha , Huang); 2 NRCT (Salam, Bidaye); 1 e o-
spec i e coho (Gul)
Agains :
No di e ence: 1 me analysis (Ya-Lei Sun)
Le el o e idence 1a
Conclusions P obably cobla o is associa ed wi h less esidual adenoid, despi e i
could no be demons a ed in a ne wo k me analysis because o he
wide con idence in e als and he e ogenei y o s udies
Ques ion 5: is cobla o adenoidec omy in pedia ic pa ien s associa ed o less e ision a e?
A ailable e idence Fa o ing: 1 e ospec i e coho (Sjog en)
Agains : 1 e ospec i e coho (Bhanda i)
No di e ence: 1 me analysis (Lee)
Le el o e idence 1a
Conclusions Cobla ion is no associa ed wi h less e ision a e compa ed o o he
adenoidec omy echniques
Ques ion 6: is cobla o adenoidec omy in pedia ic pa ien s associa ed o less pos ope a i e pain?
A ailable e idence Fa o ing: 1 me analysis (Ya-Lei Sun); 5 RCT (Hapalia, Singh, Mula c-
zyk, Gülšen, Chauhan); 1 1 NRCT (Bidaye)
Agains :
No di e ence: 1 NRCT (Salam); 2 RCT (Shapi o, El Tahan)
Le el o e idence 1a
Conclusions Cobla o is associa ed wi h less pos ope a i e pain in he i s days a e
su ge y compa ed agains mic odeb ide , cu e e and suc ion coagula-
ion
4343Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
1 3
sample size was 6.37yea s, wi h he younges mean age
being 4.58yea s by Mula czyk e al [18] (mic odeb ide
coho ) and he oldes 8.4yea s, by Di Rienzo e al [22]
(cu e e coho ).
The mean ollow-up adjus ed by sample size was
96.39days, being 730days he longes ollow-up (Bha
e al.) [15], and 1day he sho es (Bidaye e al.) [25].
Quali y o included s udies: publica ion bias
andsmall s udy bias
The isk o bias, assessed acco ding o he Na ional Ins i-
u e o Heal h and Clinical Excellence´s Quali y Assess-
men o case se ies s udies checklis , is summa ized in
Table2 o coho s udies and in Table3 o andomized
clinical ials.
Discussion
In e es in cobla ion adenoidec omy has g own conside ably
in ecen imes, as e lec ed in he li e a u e, whe e mos o
he e idence has been published in he las 10yea s.
Two p e ious sys ema ic e iews and me a-analyses
ha e been pe o med wi h he aim o assessing he po en-
ial bene i s o cobla ion adenoidec omy compa ed o o he
echniques [10, 30]. One o hem (Aleem e al.) [30] was
no included in ou s udy as i mixed adul s wi h child en,
and cobla ion wi h o he endoscopic echniques (5 o he 14
Table 1 (con inued)
Ques ion 7: is cobla o adenoidec omy in pedia ic pa ien s associa ed o imp o emen in hinomanome y?
A ailable e idence Fa o ing: 2 RCT (Di Rienzo, Huang)
Agains :
No di e ence:
Le el o e idence 1b
Conclusions Cobla o adenoidec omy dec eases mo e nasal obs uc ion compa ed o
cold cu e e
Ques ion 8: is cobla o adenoidec omy in pedia ic pa ien s associa ed o imp o emen in mucocilia y clea ance?
A ailable e idence Fa o ing: 1 RCT (Ozki is)
Agains :
No di e ence:
Le el o e idence 2b
Conclusions Cobla o adenoidec omy inc eases mo e mucocilia y clea ance com-
pa ed agains cu e e
Ques ion 9: is cobla o adenoidec omy in pedia ic pa ien s associa ed o imp o emen in eus achian ube unc ion?
A ailable e idence Fa o ing: 1 RCT (Gülšen)
Agains :
No di e ence: 1 RCT (Bha , Huang), 1 NRCT (Salam)
Le el o e idence 1b
Conclusions The chosen sample is no ep esen a i e o OME pa ien s. The e is
no e idence in his ega d. The e is no enough e idence ega ding
eus achian ube unc ion
Ques ion 10: is cobla o adenoidec omy in pedia ic pa ien s associa ed o mo e imp o emen in sleep diso de ed b ea hing?
A ailable e idence Fa o ing:
Agains :
No di e ence: 1 RCT (Huang)
Le el o e idence 2b
Conclusions The e is no e idence o sugges ha cobla ion adenoidec omy is associ-
a ed wi h mo e imp o emen o sleep diso de ed b ea hing compa ed
agains o he adenoidec omy echniques
Ques ion 11: is cobla o adenoidec omy in pedia ic pa ien s associa ed o highe cos ?
A ailable e idence Fa o ing: 1 e ospec i e coho (Sjog en)
Agains :
No di e ence:
Le el o e idence 2b
Conclusions Cobla o is mo e expensi e han cu e e ega ding di ec cos s. The e is
no e idence ega ding indi ec cos s

4344 Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
1 3
included s udies did no pe o m cobla ion). The o he s udy
(Sun e al.) [10] is a high quali y e iew and ne wo k me a-
analysis compa ing di e en adenoidec omy echniques
assessing pain, blood loss, in aope a i e ime and pos op-
e a i e esidual issue. The main p oblem wi h his s udy
was he he e ogenei y in he me hods used o assess blood
loss and in aope a i e ime, which could make compa ison
be ween g oups inapp op ia e.
The a ailable e idence is s ill sca ce in he li e a u e
and mos publica ions a e ocused on he analysis o ope a-
i e ime and in aope a i e bleeding. Howe e , ope a i e
ime and bleeding a e no he mos ele an a iables o
o ola yngologis s when selec ing one echnique o e ano he
[7], bu a he hose ha ha e o do wi h clinical ou comes.
Ques ion 1: iscobla o adenoidec omy inpedia ic
pa ien s associa ed wi hlessin aope a i e
bleeding?
Rega ding in aope a i e bleeding, 10 RCTs [12, 13,
16–23] ound di e ences in a o o cobla o . Howe e ,
he ne wo k me a-analysis by Sun e al [10] could no
iden i y any s a is ically signi ican di e ence gi en he
wide Odds a io con idence in e al. This lack o s a is i-
cal signi icance may e lec he he e ogenei y o me hods
o measu e bleeding. In addi ion, he clinical ele ance o
his di e ence emains deba able and, despi e being s a is-
ically signi ican , he di e ence be ween g oups is small
and he e o e may no be clinically impo an .
In conclusion, cobla o may be associa ed wi h less
bleeding, al hough his could no be demons a ed in a
ne wo k me a-analysis due o wide con idence in e als
and he e ogenei y o s udies.
Ques ion 2: iscobla o adenoidec omy inpedia ic
pa ien s associa ed olesspos ope a i e bleeding?
In his espec , e idence is sca ce wi h only one RCT [12]
and one coho s udy [26] ound in he li e a u e. Bo h
s udies compa e adenoidec omy wi h cobla o wi h ade-
noidec omy wi h mic odeb ide . The a ailable e idence
sugges s less pos ope a i e bleeding in he cobla o g oup.
Fo s udies compa ing cobla o and cu e age, he e is no
analysis compa ing he wo g oups.
Ques ion 3: iscobla o adenoidec omy inpedia ic
pa ien s associa ed wi hhighe ope a i e ime?
This is a ele an poin conside ing ha a p e ious s udy
ound ha one o he mos signi ican ac o s con ibu ing
o he choice o ins umen in adeno onsillec omy is he
du a ion o he p ocedu e [31].
The li e a u e sugges s ha cobla o adenoidec omy is
associa ed wi h longe ope a i e ime compa ed o cold
cu e age, howe e , i is no supe io o o he powe -
assis ed echniques such as he mic odeb ide . Thus,
he pooled da a om he ne wo k me a-analysis by Sun
e al [10] could no iden i y any s a is ically signi ican
di e ences.
The main di icul y in compa ing s udies is ha di e en
au ho s epo ope a i e ime di e en ly. Thus, some g oups
calcula e he o al ime spen in he ope a ing hea e o ope -
a ing oom, o he s calcula e i as he ime om induc ion o
Table 2 Assessmen o he isk o bias quasi-expe imen al and coho
s udy
NA no applicable, NR no epo ed, + + Well co e ed, + Adequa ely
add essed, – Poo ly add essed, 1.1 Is he sou ce popula ion o sou ce
a ea well desc ibed?, 1.2 Is he eligible popula ion o a ea ep esen a-
i e o he sou ce popula ion o a ea?, 1.3 Do he selec ed pa icipan s
o a eas ep esen he eligible popula ion o a ea?, 2.2 We e in e en-
ions well desc ibed and app op ia e?, 2.4 We e pa icipan s o in es-
iga o s blind o exposu e and compa ison?, 2.5 Was he exposu e
o he in e en ion and compa ison adequa e?, 2.8 We e all pa ici-
pan s accoun ed o a s udy conclusion?, 2.9 Did he se ing e lec
usual p ac ice?, 3.1 We e ou come measu es eliable?, 3.2 We e all
ou come measu emen s comple e?, 3.3 We e all impo an ou comes
assessed?, 3.4 We e ou comes ele an ?, 4.1 We e exposu e and com-
pa ison g oups simila a baseline? I no , we e hese adjus ed?, 4.3
Was he s udy su icien ly powe ed o de ec an in e en ion e ec (i
one exis s)?, 4.4 We e he es ima es o e ec size gi en o calcula-
ble?, 4.5 We e he analy ical me hods app op ia e?, 4.6 Was he p e-
cision o in e en ion e ec s gi en o calculable?, 5.1 A e he s udy
esul s in e nally alid (i.e., unbiased)?, 5.2 A e he indings gene al-
izable o he sou ce popula ion (i.e., ex e nally alid)?
Kim Gul Bhanda i Sjog en
1.1 + + + + + + + +
1.2 + + + + + + + +
1.3 + + + + + + + +
2.2 + + + + + + +
2.4 – – NR –
2.5 + + + + + + + +
2.8 + + + NR NR
2.9 + + + + + + + +
3.1 + + + + + + + +
3.2 + + + + + + + +
3.3 + + + + +
3.4 + + + + + + + +
4.1 + + + + + + +
4.3 – – + + + +
4.4 – – – –
4.5 + + + + + + +
4.6 – – – –
5.1 + +
5.2 + + +
4345Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
1 3
anes hesia o he end o su ge y [19], o he s un il he pa ien
wakes up o un il hemos asis is comple ed, [12, 23]; while
o he s do no explain i clea ly [21, 27].
Shapi o e al [23], who we e he only g oup o ind less
ope a i e ime compa ed o cold dissec ion, in hei s udy
hey measu ed ope a i e ime including hemos asis, which
could jus i y his di e ence.
In conclusion, cobla o may be associa ed wi h longe
ope a i e ime, al hough his could no be demons a ed in a
ne wo k me a-analysis due o wide con idence in e als and
he e ogenei y o s udies.
Ques ion 4: iscobla o adenoidec omy inpedia ic
pa ien s associa ed oless esidual adenoid?
A dis inc ion mus be made be ween simple adenoid pe -
sis ence, which anges be ween 1.3 and 26% [32], and
ein e en ion, which anges be ween 0.5 and 2% [33].
Adenoid pe sis ence, al hough no impo an pe se, is el-
e an , as pe sis ence o adenoid issue a 1mon h a e su -
ge y has been ela ed o adenoid eg ow h a 1-yea ollow-
up. The e o e, he pe sis ence o some deg ee o adenoid
issue a e su ge y is o impo ance, and su ge y should
aim o emo e as much adenoid issue as possible [26]. In
e ms o wha we ound in he e idence, all s udies, wi h
he excep ion o Sun e al. me a-analysis [10], ound ewe
esidual adenoids in he cobla o g oup. The Sun e al.
ne wo k me a-analysis [10] did ind mo e esidual adenoid
issue in he cu e e g oup compa ed o he cobla o g oup,
al hough his di e ence was no s a is ically signi ican .
In conclusion, cobla o is p obably associa ed wi h less
esidual adenoids, al hough his could no be demons a ed
in a ne wo k me a-analysis due o he wide con idence
in e als and he e ogenei y o he s udies.
Ques ion 5: iscobla o adenoidec omy inpedia ic
pa ien s associa ed oless e ision a e?
A di e en aspec o symp oms o ecu ence (ques ion 4), is
ein e en ion. No all pa ien s wi h adenoid ecu ence ha e
symp oms se e e enough o jus i y su gical ein e en ion.
Some au ho s ha e hypo hesized ha cobla ion may c ea e
ib osis in he lamina p op ia and less lymphocy e in il a e,
which may be ela ed o a mo e s able and de ini i e con ol
Table 3 Assessmen o he isk o bias o clinical ial
NA no applicable, NR no epo ed, + + Well co e ed, + Adequa ely add essed, – Poo ly add essed, A1 An app op ia e me hod o andomiza ion
was used o alloca e pa icipan s o ea men g oups (which would ha e balanced any con ounding ac o s equally ac oss g oups), A2 The e was
adequa e concealmen o alloca ion (such ha in es iga o s, clinicians and pa icipan s canno in luence en olmen o ea men alloca ion), A3
The g oups we e compa able a baseline, including all majo con ounding and p ognos ic ac o s, B1 The compa ison g oups ecei ed he same
ca e apa om he in e en ion(s) s udied, B2 Pa icipan s ecei ing ca e we e kep 'blind' o ea men alloca ion, B3 Indi iduals adminis e -
ing ca e we e kep 'blind' o ea men alloca ion, C1 All g oups we e ollowed up o an equal leng h o ime (o analysis was adjus ed o allow
o di e ences in leng h o ollow-up), C2 The g oups we e compa able o ea men comple ion ( ha is, he e we e no impo an o sys ema ic
di e ences be ween g oups in e ms o hose who did no comple e ea men ), C3 The g oups we e compa able wi h espec o he a ailabili y
o ou come da a ( ha is, he e we e no impo an o sys ema ic di e ences be ween g oups in e ms o hose o whom ou come da a we e no
a ailable), D1 The s udy had an app op ia e leng h o ollow-up, D2 The s udy used a p ecise de ini ion o ou come, D3 A alid and eliable
me hod was used o de e mine he ou come, D4 In es iga o s we e kep 'blind' o pa icipan s' exposu e o he in e en ion, D5 In es iga o s we e
kep 'blind' o o he impo an con ounding and p ognos ic ac o s
Sing Hapalia Huang Bha Gulsen Chauhan Mula czycs el ahan Balasub amanian Ozki is di ienzo Shapi o Salam Bidaye
A1 + + + + + + + + + + + + + + + +
A2 + – – – + + + – – + + –
A3 + + – + + + + + + + + + + – + + + +
B1 + + + + + + + + + + + + + + + + + + + + +
B2 + + – – – – + + – – + + + + –
B3 – – – – – – – – /NR – – –
C1 + + + + + + + + + + + + + – + + + + +
C2 + + + + + + + + + + + + + + + +
C3 + + + + + + + + + + + + + + – + + + + + +
D1 + + + + + + + + + + + + – / + + + + + + +
D2 + + + + + + + + + + + + – + + + + + +
D3 + + + + + + + + + + – + + + + +
D4 – – – – – – – – – – –
D5 – – – – – – – – – – –
4346 Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
1 3
o adenoid hype ophy [22]. Howe e , he only me a-analy-
sis (Lee e al.) [11] ha e alua ed he e ision a e acco ding
o di e en adenoidec omy echniques could no iden i y any
signi ican di e ence be ween excisional me hods.
In conclusion, cobla ion is no associa ed wi h a lowe
e ision a e compa ed o o he adenoidec omy echniques.
Ques ion 6: iscobla o adenoidec omy inpedia ic
pa ien s associa ed olesspos ope a i e pain?
Ano he a iable ha could jus i y he selec ion o one ech-
nique o e ano he is pain. A o al o 10 s udies analyzed
pain in ensi y [10, 12, 13, 16–19, 23–25], including one
me a-analysis [10]. Sun e al. ne wo k me a-analysis [10]
epo ed signi ican ly lowe pain in he cobla o g oup com-
pa ed o he cold cu e e g oup, mixing VAS sco e esul s
(mean di e ence = 3.45, 95% CI [0.95, 6.01]).
The a ailable e idence is s ong. Cobla ion was associ-
a ed wi h less pain compa ed o cold cu e age in he i s
days a e su ge y [10, 12, 13, 16–18, 25]. Howe e , no di -
e ence was ound a 1week, [16] esul s ha a e simila
when compa ed o he mic odeb ide echnique. [12]
This di e ence in pain in ensi y is s a is ically signi ican .
Howe e , his di e ence is mild, he e o e, i is no clea i s
clinical ele ance.
Ques ion 7: iscobla o adenoidec omy inpedia ic
pa ien s associa ed wi hg ea e imp o emen
innasal obs uc ion?
The e a e no s udies using quali y o li e su eys such as
sinus and nasal quali y o li e ques ionnai es. Rega ding
symp oms, he e is only one s udy wi h hinomanome y
[22], wi h be e esul s o cobla o compa ed o cu e e.
Rhinomanome y, wi h and wi hou deconges an , is a good
diagnos ic ool ha has been p oposed o selec child en o
adenoidec omy. [34]
The o he s udy, by Huang e al. [14] only assessed VAS
sco e, bu he imp o emen was also mo e no iceable in he
cobla o coho compa ed o cu e e.
In conclusion, he a ailable e idence is sca ce. I sug-
ges s ha cobla o adenoidec omy is associa ed wi h g ea e
imp o emen in nasal obs uc ion compa ed o cold cu e e.
Ques ion 8: iscobla o adenoidec omy inpedia ic
pa ien s associa ed oimp o emen inmucocilia y
clea ance?
Only one g oup s udied mucocilia y anspo ime (MCTT)
[21]. Fo his pu pose, hey used scin ig aphy and obse ed
ha cobla ion adenoidec omy imp o ed MCTT, whe eas
cold cu e e did no .
The jus i ica ion o his di e ence could be ha adenoid
hype ophy is associa ed wi h hini is [35]. Cobla o ade-
noidec omy may sol e be e he hini is, imp o ing MCTT.
Ano he explana ion may be nasal obs uc ion associa ed
wi h adenoid hype ophy. Lack o nasal b ea hing has
been ound o be a de imen al ac o in MCTT. The e o e,
imp o emen in MCTT may e lec imp o emen in nasal
b ea hing, which has been assessed in ques ion 7, and cobla-
o seems o o e be e esul s han cu e e.
In conclusion, he e idence is sca ce. The a ailable
e idence sugges s ha cobla o adenoidec omy is associ-
a ed wi h g ea e imp o emen in MCTT compa ed o cold
cu e age.
Ques ion 9: iscobla o adenoidec omy inpedia ic
pa ien s associa ed oimp o emen ineus achian
ube unc ion?
Al hough OME is one o he main indica ions o adenoid-
ec omy, he e a e ew s udies e alua ing his a iable in
he li e a u e. Tubal onsil is a equen si e o ecu ence
[36] and he e o e, a sou ce o pe sis en symp oms a e
adenoidec omy [36, 37]. Howe e , he e is eason o belie e
ha cobla ion may o e be e esul s in he managemen o
OME p obably jus i ied because endoscopic ision o e s
be e con ol o he uba ic onsils.
Two o he h ee au ho s who e alua ed Eus achian ube
unc ion excluded pa ien s wi h OME [15, 16], so, al hough
ema kable, hei coho is no ep esen a i e o eal pa ien s.
Gülsen e al [16] epo ed no Eus achian ube dys unc ion
in he i s days a e su ge y in he cobla ion coho , while
19.4% o cu e age pa ien s had Eus achian ube dys unc ion
in he i s days a e su ge y, e u ning o no mal alues
wi hin one week. Bha e al [15] epo ed no di e ence in
middle ea p essu e a e 3mon hs ollow-up. Again, he
sample was also no ep esen a i e o he eal a ge popula-
ion, pa ien s wi h OME.
In conclusion, he sample chosen in he men ioned s ud-
ies was no ep esen a i e o pa ien s wi h OME. The e o e,
he e is no e idence in his espec exis ing insu icien
e idence on he Eus achian ube unc ion in ela ion o he
adenoidec omy echnique pe o med.
Ques ion 10: iscobla o adenoidec omy inpedia ic
pa ien s associa ed wi hg ea e imp o emen
insleep diso de ed b ea hing?
Only one RCT [14] has been ound e alua ing his a iable.
In his s udy, hey we e unable o iden i y any s a is ically
signi ican di e ence when compa ing cobla o adenoid-
ec omy wi h adenoidec omy wi h cu e age. Al hough iso-
la ed adenoidec omy may ha e some ole in he ea men o
pedia ic sleep diso de ed b ea hing [38], i s ole is limi ed.
4347Eu opean A chi es o O o-Rhino-La yngology (2023) 280:4339–4349
1 3
The e o e, he su gical echnique o adenoidec omy is no
expec ed o in luence his ou come.
Ques ion 11: iscobla o adenoidec omy inpedia ic
pa ien s associa ed wi hahighe cos ?
The las impo an a iable in luencing he p e e ed ins u-
men o echnique is cos [31]. The equipmen equi ed o
cobla ion is signi ican ly mo e expensi e han o he op ions
such as cold cu e age o elec ocau e y. Howe e , he cos
analysis mus ake in o accoun addi ional cos s including
he du a ion o su ge y, pa en al days o wo k, use o anal-
gesics, complica ion a e and e ision su ge y, among o he s.
The e is only one cos s udy [29] ha desc ibes a alue o
$200 mo e pe pa ien compa ed o cold cu e e echnique,
bu $35 less han he mic odeb ide . Howe e , in his s udy
only he di ec cos s we e conside ed, wi hou aking in o
accoun he addi ional cos s men ioned abo e.
In conclusion, he cobla o is mo e expensi e han he
cu e e in e ms o di ec cos s wi h no e idence on indi ec
cos s.
Al hough he abo e esul s could guide ou decision on
he choice o echnique, he e a e se e al con ounding ac-
o s ha could impai he analysis.
Adenoid size is an impo an con ounde . I has been
epo ed o be ela ed o ecu ence a e [39], and pos op-
e a i e pain [18] bu only one au ho [18] ha e con olled
his con ounding ac o in a s a i ied analysis.
Ano he con ounding ac o o conside is he su gical
c i e ia, as mos au ho s did no speci y he su gical c i e-
ia. Su ge y may be indica ed o se e al easons including
sleep apnea, OME, ch onic hinosinusi is o nasal obs uc-
ion and esul s may di e acco ding o he indica ion. As
an example, a mul i a ia e analysis showed ha he e is a
signi ican isk o e ision adenoidec omy o pa ien s wi h
an ea - ela ed indica ion o adenoidec omy, (OR 10.8) [40].
Howe e , o all he selec ed s udies, only Huang e al [14]
we e he only ones o pe o m a subg oup analysis wi h
espec o su gical indica ion.
Su gical echnique and su geon skills may also in luence
ou comes. Thus, le el o aining has been epo ed o be a
ac o ela ed o he isk o e ision su ge y, wi h pa ien s
ope a ed on by ainees being 50% mo e likely o equi e
e ision su ge y [40]. Likewise, he ex en o adenoidec omy
has been epo ed o be he mos impo an ac o ela ed o
he ecu ence a e [41].
Cobla o can be u ilized ollowing di e en me hods, as
i can be used h ough he nose o h ough he mou h. As
well as he way o isualize he adenoids, using a ansnasal
endoscope, anso al angula ed endoscope o anso al mi -
o . I can also change he powe se , acco ding o he deli -
e ed ene gy. The e a e no s udies compa ing hese a iables.
Finally, younge age has been p oposed in se e al s ud-
ies as a ac o posi i ely ela ed o adenoid eg ow h and
e ision su ge y, as each yea dec eases he isk o e ision
su ge y by 30%. Howe e , none o he au ho s ha e s a i ied
hei esul s acco ding o age.
Ano he po en ial con ounding ac o no conside ed in
his e iew is he concomi an onsillec omy. In his e iew
we ha e excluded s udies wi h concomi an su ge y. This
sample may no e lec he common pa ien , as usually ade-
noidec omy is associa ed wi h onsillec omy.
Cobla o can be used in di e en ways, as i can be pe -
o med ei he h ough he nose o h ough he mou h. The
same applies o he ype o ins umen used o isualize he
adenoids, ei he using a ansnasal endoscope, an angled an-
so al endoscope o a anso al mi o . Fu he mo e, he powe
se ing may also a y depending on he ene gy deli e ed. In
his espec , he e a e no s udies compa ing hese a iables.
Rega ding o age, younge age has been p oposed in se e al
s udies as a ac o posi i ely ela ed o adenoid eg ow h [39],
and e ision su ge y, as each yea dec eases he isk o e i-
sion su ge y by 30% [40]. Howe e , none o he au ho s ha e
s a i ied hei esul s acco ding o age in his ega d ei he .
Ano he po en ial con ounding ac o no conside ed in
his e iew is concomi an onsillec omy, as s udies wi h
concomi an su ge y ha e been excluded; consequen ly, i
is possible ha his sample does no e lec he common
pa ien , hus adenoidec omy is usually associa ed wi h
onsillec omy.
Finally, i should be kep in mind ha cobla ion adenoid-
ec omy may ha e i s own isks and disad an ages ha should
be measu ed agains i s bene i s. The mos ema kable is
ha i may impai he p esence o enough issue o pe o m
his ology assessmen . In ac , despi e he e idence is sca ce,
some au ho s ha e sugges ed ha some seconda y e ec s a e
mo e p one o occu wi h he cobla ion han mic odeb ide
[42].
Conclusion
Cobla o adenoidec omy appea s o o e be e adenoid
con ol compa ed o cu e age, wi h a possible, al hough
no con i med lowe a e o e ision su ge y. Simila ly, his
g ea e esec ion o adenoid issue seems o be ela ed o a
g ea e educ ion o nasal obs uc ion.
The ad an ages o his echnique a e mainly less su gical
bleeding- al hough i is no clea his is a clinically ele an
di e ence-, and less pos ope a i e pain compa ed o cold
cu e age. The di e ence in pain is small, as adenoidec omy
is no a pain ul su ge y in gene al. The e is li le e idence on
he con ol o OME and compa ison wi h o he echniques
such as mic odeb ide adenoidec omy.